Approach

The goal of treatment is the eradication of bacteria; antimicrobial agents are the primary means of therapy.

Symptomatic men with culture-proven urinary tract infection (UTI) should be treated with antimicrobial agents.[2]

Men with a positive urinalysis by dipstick or microscopic examination and specific symptoms (dysuria, frequency, urgency, suprapubic pain, or costovertebral angle pain) should receive empirical therapy until the culture results demonstrate absence of significant bacteriuria or suggest need for a different antimicrobial based on the sensitivities provided.

Catheter-associated UTI (a complicated UTI [cUTI]) must be treated with diligence because of the risk of developing bacteraemia, but screening for or treatment of asymptomatic bacteriuria in catheterised patients is not recommended.[6][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.​[2]

Intravenous therapy and hospitalisation are indicated for patients who are severely ill, such as in cases of suspected bacteraemia.[2] Intravenous therapy is continued until the patient is stabilised and afebrile. Illness severity is judged by the presence of a generally toxic-appearing patient, with fever, tachycardia, tachypnoea, hypotension, or an elevated white blood cell count. The decision to hospitalise can also be based on the patient's inability to take medications orally (e.g., in cases of protracted vomiting). For patients with UTI who are otherwise immunocompromised, the clinician should maintain a lower threshold for hospitalisation.

Choice of antibiotics

Treating UTI in men differs from female UTI therapy. Most recommendations derive from data regarding women, but men more often have UTI classified as complicated. The Infectious Diseases Society of America (IDSA) recommends a four-step approach to account for changing resistance patterns and specific patient needs. The approach specifically states to assess the severity of illness, the risk factors for resistance, any patient-specific considerations, and, if the patient is septic, consider the local antibiogram if available.[1]​ The European Association of Urologists (EAU) notes that cystitis in men without involvement of the prostate is uncommon so this needs consideration in antibiotic choice to ensure treatment penetrates into the prostate tissue.[2]

All men should have a urine culture to assure that the initial empirical antibiotic choice is appropriate.

The goal of therapy (eradication of bacteria) and the primary means of therapy (oral antibiotics) remain the same for both men and women. The basic principles of choosing an antibiotic include:

  • Identifying the probable organism causing the infection

  • Identifying the patient's prior hypersensitivities

  • Weighing the potential adverse effects

  • Considering the presence of renal or liver disease

  • Considering the cost of therapy.

The choice of initial empirical therapy should be guided by local resistance patterns as well as previous organisms identified from the patient and associated antimicrobial susceptibility testing data in the last 12 months, along with the patient’s antibiotic exposure within the past 3 months.[2][78]​​​​​[79]

Treatment options include beta-lactam antibiotics (often in combination with other antibiotics [e.g., aminoglycosides]) and trimethoprim/sulfamethoxazole.[1] Fluoroquinolones can be considered where resistant levels are <10%.[2] Nitrofurantoin is only ever considered for lower UTIs, as it does not penetrate well into the prostate and is not suitable for upper UTIs or patients with systemic symptoms.[80][81]​​​​

Overall, Escherichia coli causes the majority of UTIs. However, E coli is identified as the causative organism in less than 50% of men with UTI, so a more variable group of bacterial species must be considered.[5][8][16][21][29][31]​​​[82]​​​[83]​​[84]​​ Additional microorganisms causing UTI in men include Klebsiella, Proteus, Providencia, Enterococcus, and Staphylococcus. Catheter-related UTI may also be associated with Pseudomonas and resistant organisms.

Therefore, guideline recommendations for first-line empirical therapy for UTI in women may not apply to men.[2][85]​​​ Some guidelines suggest using trimethoprim/sulfamethoxazole first-line if local E coli resistance patterns are less than 20%. However, US data suggest that trimethoprim/sulfamethoxazole resistance ranges between 18% and 22%.[84] A trial involving men in German outpatient settings noted 34% resistance to trimethoprim/sulfamethoxazole.[21] Risk factors identified for having an infection resistant to trimethoprim/sulfamethoxazole include recent use of trimethoprim/sulfamethoxazole or any antibiotic and recent hospitalisation.[86]

Depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics can be a reasonable first-line treatment of UTI in men due to the higher risk of a complicated course in this patient group.[1][2]​ One 2023 observational study indicated that in a setting with a high prevalence of fluoroquinolone-resistant microorganisms, the use of fluoroquinolones as directed treatment for complicated community-acquired UTI was associated with better outcomes than other antibiotics.[87] However, it did suggest that they should not be used for empirical treatment.

The European Association of Urology also recommends against the use of fluoroquinolones for the empirical treatment of complicated/systemic UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months, due to the high level of resistance.[2]

Of note, oral antibiotic therapy, and specifically ciprofloxacin, compared favourably with intravenous ciprofloxacin in a trial of 141 patients with pyelonephritis, community-acquired UTI, or hospital-acquired UTI.[88][89]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[90]

  • Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

  • Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

In the setting of increasing drug resistance in uropathogens, carbapenems and novel broad-spectrum antimicrobial agents can be considered in patients with early culture results indicating the presence of multidrug-resistant organisms. The choice between these agents should be based on local resistance patterns and on the basis of drug susceptibility results.[1][2]

The following treatments are approved in some countries for use in adults with cUTI caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[91][92][93][94][95][96]

Length of therapy

Complicated infections require longer therapy. Most authorities recommend 7-14 days in men; 14 days when prostatitis cannot be excluded, and based on clinical response and selected agent. The shorter 7-day treatment (5-7 days of a fluoroquinolone, 7 days of a non-fluoroquinolone antibiotic) course can be considered if the patient is stable, clinically improving and has remained afebrile for at least 48 hours.[1][2][16]​​​​​[97] However, in males with systemic UTIs and fever; studies have shown that 7 days of antibiotic treatment is inferior to 14 days, so a longer course is generally warranted.[98]

In younger men, complicated infections occur less frequently. They may also have a clearly identifiable risk for UTI, such as sexual activity, and 7 days of therapy is generally adequate. In one randomised controlled trial study looking at afebrile men with suspected UTI, treatment with ciprofloxacin or trimethoprim/sulfamethoxazole for 7 days was non-inferior to 14 days of treatment with regard to resolution of UTI symptoms.[99]

Treatment failure and recurrence

When treatment fails, as evidenced by incomplete resolution of urinary tract symptoms or development of complications secondary to UTI, then a comprehensive evaluation of the urinary tract with imaging should be pursued to identify possible underlying structural or functional abnormalities. Identifying and correcting such abnormalities may be required for successful clearance of UTI.

In addition, poor response to therapy in the short term may indicate the presence of upper tract infection (pyelonephritis) and a need for intravenous therapy, or it may signal the presence of peri-renal abscess requiring surgical drainage. Urology consultation should be considered for men with treatment failure.

After completing acute UTI treatment, it is good practice to arrange clinical follow-up to ensure resolution of symptoms and completion of antibiotic therapy, and seek to identify factors that may indicate cUTI. The patient should be informed that recurrence of UTI necessitates detailed evaluation of the urinary tract with imaging.

Asymptomatic bacteriuria

Treatment of asymptomatic bacteriuria is not recommended in most cases, because it does not alter morbidity or mortality.[6] However, before a urological procedure that may disrupt the urinary tract lining, an attempt should be made to sterilise the urine to decrease the risk of bacteraemia and sepsis. The optimal choice of antibiotics depends on several factors, including the likely local organisms and local resistance patterns, the anatomical site, the type, duration, and invasiveness of the procedure being performed. The duration of treatment also varies according to the procedure. A single dose given preoperatively is generally considered appropriate in the majority of uncomplicated procedures.[100] A urine culture with antibiotic sensitivities obtained several days before the procedure will help guide antibiotic choices.

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