Urinary Tract Infections in Males

Introduction

• Urinary tract infections (UTIs) require careful management to prevent complications and reduce the risk of antibiotic resistance, as recommended by the American College of Physicians and the Infectious Diseases Society of America 1, 2, 3, 4, 5
• Treatment is only indicated for symptomatic UTI, as suggested by the British medical guidelines 6

Prevention

• Encourage adequate hydration (2-3L/day) to reduce UTI risk and prevent sickle cell disease (SCD) complications, as recommended by the British medical guidelines 6
• Increasing fluid intake, postcoital voiding, and avoiding prolonged urine retention are recommended for prevention of UTIs, as suggested by the American Urological Association 7
• Non-antimicrobial measures, such as increased fluid intake, vaginal estrogen replacement, and probiotics, may be considered for prevention of recurrent UTIs, as recommended by the American Urological Association and the Infectious Diseases Society of America 2, 7

Diagnosis

• Obtain a urine specimen for culture prior to initiating antimicrobial therapy to identify the infecting organism and determine antimicrobial resistance, as recommended by the American College of Physicians 1, 2
• A high colony count (>100,000 cfu/ml) in a urine culture suggests true infection, and is a key factor in diagnosing UTIs, with a clean-catch or catheterized specimen recommended to confirm the diagnosis 3, 8
• Differentiate between colonization and true infection before initiating treatment, with a pure growth of ≥50,000 CFUs/mL of S. epidermidis suggesting true infection 1

Antibiotic Treatment

• The European Association of Urology recommends cefpodoxime 200 mg twice daily for 7 days as an oral antibiotic option for male patients with UTI sensitive to cefotaxime, due to its similar spectrum to cefotaxime and good urinary concentrations 2
• Cefixime 400 mg once daily for 7 days is an alternative oral third-generation cephalosporin listed in the European Association of Urology guidelines for uncomplicated pyelonephritis 2
• Ciprofloxacin 500 mg twice daily for 7 days may be considered if the patient has normal renal function and low local fluoroquinolone resistance (<10% locally), as recommended by the European Association of Urology 2
• First-line treatment options include:
• Alternative options include:
• The following antimicrobial agents can be used for UTI treatment, with their respective daily doses and comments:

Special Considerations

• For patients with reduced renal function (GFR 26) and penicillin allergy, the American Journal of Kidney Diseases recommends reduced-dose fluoroquinolones, specifically ciprofloxacin 400mg IV q24h, as the most appropriate first-line IV antibiotic treatment 9
• The American Journal of Kidney Diseases advises against using nitrofurantoin in patients with GFR less than 30 ml/min/1.73m² due to reduced efficacy and increased toxicity risk 9
• The American Academy of Pediatrics recommends considering fluoroquinolones only when infection is caused by multidrug-resistant pathogens with no safe and effective alternative, due to the risks of musculoskeletal adverse events and increasing bacterial resistance 10
• For diabetic patients with recurrent UTIs, consider prophylactic antibiotics if recurrences are frequent, as recommended by the American Urological Association 11
• For SCD patients with frequent recurrences, consider prophylactic antibiotics after medical review, according to the British medical guidelines 6

Treatment Duration and Monitoring

• Monitor clinical response within 72 hours of initiating therapy, and consider extending treatment duration, performing urologic evaluation, or adjusting antimicrobial regimen based on culture and susceptibility results if no improvement occurs 1
• Treatment duration is 7 days for patients with prompt resolution of symptoms, and 10-14 days for those with delayed response, as recommended by the American Urological Association and the Infectious Diseases Society of America 1, 2, 7
• Discontinue urinary catheters as soon as possible, and remove them completely if no longer needed 1
• If an indwelling catheter has been in place for ≥2 weeks at the onset of UTI and is still indicated, replace the catheter to hasten symptom resolution and reduce risk of subsequent bacteriuria and UTI 1