Urinary tract infections in men
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
asymptomatic bacteriuria before urologic procedure
oral antibiotic therapy
The purpose of therapy is to temporarily eliminate bacteriuria, because the presence of nonsterile urine during urologic procedures increases the risk of bacteremia and sepsis.
The optimal choice of antibiotics depends on several factors, including the likely local organisms and local resistance patterns, the anatomic site, the type, duration, and invasiveness of 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.[103]American Urological Association. Urologic procedures and antimicrobial prophylaxis (2019). Jun 2019 [internet publication]. https://www.auanet.org/guidelines-and-quality/quality-and-measurement/quality-improvement/clinical-consensus-statement-and-quality-improvement-issue-brief-(ccs-and-qiib)/urologic-procedures-and-antimicrobial-prophylaxis-(2019)
A urine culture with antibiotic sensitivities obtained several days before the procedure will help guide antibiotic choices. Consult your local protocols for guidance on antibiotic selection and doses.
After the procedure, the antibiotic can be discontinued unless a catheter remains in place.
not severe and tolerating oral therapy
oral antibiotic therapy
The choice of initial empiric 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]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections [81]Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis. 2024 Aug 7:ciae403. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciae403/7728556 http://www.ncbi.nlm.nih.gov/pubmed/39108079?tool=bestpractice.com [82]Faine BA, Rech MA, Vakkalanka P, et al. High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020. Acad Emerg Med. 2022 Sep;29(9):1096-105. https://onlinelibrary.wiley.com/doi/10.1111/acem.14545 http://www.ncbi.nlm.nih.gov/pubmed/35652493?tool=bestpractice.com
The Infectious Diseases Society of America 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]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections
All men should have a urine culture to assure that the initial empiric antibiotic choice is appropriate.
Treatment options include beta-lactams (e.g., amoxicillin/clavulanate, cephalexin), trimethoprim/sulfamethoxazole, and fluoroquinolones (e.g., levofloxacin, ciprofloxacin).[1]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections [2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections [14]Schaeffer AJ, Nicolle LE. Clinical practice. Urinary tract infections in older men. N Engl J Med. 2016 Feb 11;374(6):562-71.
Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications such as pseudomembranous colitis or induction of resistance.
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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[93]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com 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.
However, depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[1]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections [2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empiric treatment of complicated UTI (cUTI) in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections Trimethoprim/sulfamethoxazole may be used first-line in younger men without evidence of cUTI and with consideration to local resistance patterns.
Antibiotic dosing may need to be altered based on the patient's renal status.
Catheter-associated UTI (a cUTI) must be treated with diligence because of the risk of developing bacteremia, but screening for or treatment of asymptomatic bacteriuria in catheterized patients is not recommended.[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com [Evidence A]f8feace8-583e-4f51-9df9-c66506ddc282guidelineAShould patients with a long-term indwelling urethral catheter be screened or treated for asymptomatic bacteriuria (ASB)?[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com [Evidence C]6ee479d8-33d2-4f81-9603-8836e091590cguidelineCShould patients with an indwelling urethral catheter for <30 days be screened or treated for asymptomatic bacteriuria (ASB)?[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com If therapy is initiated, then the catheter should be changed before starting antibiotics.[2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections
Treatment for 7-14 days is generally recommended.[2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections
Primary options
sulfamethoxazole/trimethoprim: 160 mg orally twice daily for 7-14 days
More sulfamethoxazole/trimethoprimDose refers to trimethoprim component.
OR
amoxicillin/clavulanate: 500 mg orally three times daily for 7-14 days; or 875 mg orally twice daily for 7-14 days
More amoxicillin/clavulanateDose refers to amoxicillin component.
OR
cephalexin: 500 mg orally twice to four times daily for 7-14 days
OR
levofloxacin: 750 mg orally once daily for 7-14 days
OR
ciprofloxacin: 500 mg orally twice daily for 7-14 days
severe or not tolerating oral therapy
hospitalization plus intravenous antibiotic therapy
The choice of initial empiric 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.[81]Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis. 2024 Aug 7:ciae403. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciae403/7728556 http://www.ncbi.nlm.nih.gov/pubmed/39108079?tool=bestpractice.com [82]Faine BA, Rech MA, Vakkalanka P, et al. High prevalence of fluoroquinolone-resistant UTI among US emergency department patients diagnosed with urinary tract infection, 2018-2020. Acad Emerg Med. 2022 Sep;29(9):1096-105. https://onlinelibrary.wiley.com/doi/10.1111/acem.14545 http://www.ncbi.nlm.nih.gov/pubmed/35652493?tool=bestpractice.com [104]Kranz J, Bartoletti R, Bruyère F, et al. European Association of urology guidelines on urological infections: summary of the 2024 guidelines. Eur Urol. 2024 Jul;86(1):27-41. https://www.sciencedirect.com/science/article/pii/S0302283824022632 http://www.ncbi.nlm.nih.gov/pubmed/38714379?tool=bestpractice.com
The Infectious Diseases Society of America 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]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections
All men should have a urine culture to assure that the initial empiric antibiotic choice is appropriate.
Treatment options include beta-lactam antibiotics (e.g., ceftriaxone, ampicillin, imipenem/cilastatin, aztreonam, piperacillin/tazobactam) often in combination with other antibiotics (e.g., aminoglycosides such as gentamicin), and fluoroquinolones (e.g., levofloxacin, ciprofloxacin).[1]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections [2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections [14]Schaeffer AJ, Nicolle LE. Clinical practice. Urinary tract infections in older men. N Engl J Med. 2016 Feb 11;374(6):562-71.
In the setting of increasing drug resistance in uropathogens, carbapenems (e.g., imipenem/cilastatin) and novel-broad spectrum antimicrobial agents can be considered in patients with early culture results indicating multidrug-resistant organisms. The choice between these agents should be based on local resistance patterns and on the basis of drug susceptibility results.[1]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections [2]European Association of Urology. Guidelines on urological infections. Mar 2025 [internet publication]. https://uroweb.org/guidelines/urological-infections
The following treatments are approved by the Food and Drug Administration (FDA) for use in adults with complicated UTI (cUTI) caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[94]Dhillon S. Meropenem/vaborbactam: a review in complicated urinary tract infections. Drugs. 2018 Aug;78(12):1259-70. https://www.doi.org/10.1007/s40265-018-0966-7 http://www.ncbi.nlm.nih.gov/pubmed/30128699?tool=bestpractice.com [95]Wagenlehner FME, Cloutier DJ, Komirenko AS, et al. Once-daily plazomicin for complicated urinary tract infections. N Engl J Med. 2019 Feb 21;380(8):729-40. https://www.doi.org/10.1056/NEJMoa1801467 http://www.ncbi.nlm.nih.gov/pubmed/30786187?tool=bestpractice.com [96]Bassetti M, Echols R, Matsunaga Y, et al. Efficacy and safety of cefiderocol or best available therapy for the treatment of serious infections caused by carbapenem-resistant Gram-negative bacteria (CREDIBLE-CR): a randomised, open-label, multicentre, pathogen-focused, descriptive, phase 3 trial. Lancet Infect Dis. 2020 Oct 12 [Epub ahead of print]. https://www.doi.org/10.1016/S1473-3099(20)30796-9 http://www.ncbi.nlm.nih.gov/pubmed/33058795?tool=bestpractice.com [97]Lee YR, Yeo S. Cefiderocol, a new siderophore cephalosporin for the treatment of complicated urinary tract infections caused by multidrug-resistant pathogens: preclinical and clinical pharmacokinetics, pharmacodynamics, efficacy and safety. Clin Drug Investig. 2020 Oct;40(10):901-13. https://www.doi.org/10.1007/s40261-020-00955-x http://www.ncbi.nlm.nih.gov/pubmed/32700154?tool=bestpractice.com [98]Sims M, Mariyanovski V, McLeroth P, et al. Prospective, randomized, double-blind, Phase 2 dose-ranging study comparing efficacy and safety of imipenem/cilastatin plus relebactam with imipenem/cilastatin alone in patients with complicated urinary tract infections. J Antimicrob Chemother. 2017 Sep 1;72(9):2616-26. https://www.doi.org/10.1093/jac/dkx139 http://www.ncbi.nlm.nih.gov/pubmed/28575389?tool=bestpractice.com [99]Hsueh SC, Chao CM, Wang CY, et al. Clinical efficacy and safety of cefiderocol in the treatment of acute bacterial infections: a systematic review and meta-analysis of randomised controlled trials. J Glob Antimicrob Resist. 2021 Mar;24:376-82. https://www.sciencedirect.com/science/article/pii/S2213716521000369 http://www.ncbi.nlm.nih.gov/pubmed/33596476?tool=bestpractice.com
Intravenous antibiotics are continued until the patient is stabilized and can tolerate oral therapy.
Risks relate to the specific adverse effects of the antibiotic chosen and general antibiotic complications, such as pseudomembranous colitis or induction of resistance.
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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[93]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804. https://www.mdpi.com/1999-4923/15/3/804 http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com 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.
However, depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics nevertheless remain a reasonable first-line choice for treatment of UTI in men due to the higher risk of a complicated course in this patient group.[1]Infectious Diseases Society of America. Complicated urinary tract infections (cUTI): clinical guidelines for treatment and management. 2025 [internet publication]. https://www.idsociety.org/practice-guideline/complicated-urinary-tract-infections [104]Kranz J, Bartoletti R, Bruyère F, et al. European Association of urology guidelines on urological infections: summary of the 2024 guidelines. Eur Urol. 2024 Jul;86(1):27-41. https://www.sciencedirect.com/science/article/pii/S0302283824022632 http://www.ncbi.nlm.nih.gov/pubmed/38714379?tool=bestpractice.com
Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empiric treatment of cUTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[104]Kranz J, Bartoletti R, Bruyère F, et al. European Association of urology guidelines on urological infections: summary of the 2024 guidelines. Eur Urol. 2024 Jul;86(1):27-41. https://www.sciencedirect.com/science/article/pii/S0302283824022632 http://www.ncbi.nlm.nih.gov/pubmed/38714379?tool=bestpractice.com
Dosing may need to be altered based on the patient's renal status, and consideration should be given to the possibility of Pseudomonas infection in catheterized patients.
Catheter-associated UTI (a cUTI) must be treated with diligence because of the risk of developing bacteremia, but screening for or treatment of asymptomatic bacteriuria in catheterized patients is not recommended.[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com [Evidence A]f8feace8-583e-4f51-9df9-c66506ddc282guidelineAShould patients with a long-term indwelling urethral catheter be screened or treated for asymptomatic bacteriuria (ASB)?[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com [Evidence C]6ee479d8-33d2-4f81-9603-8836e091590cguidelineCShould patients with an indwelling urethral catheter for <30 days be screened or treated for asymptomatic bacteriuria (ASB)?[6]Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2019 May 2;68(10):e83-e110. https://www.doi.org/10.1093/cid/ciy1121 http://www.ncbi.nlm.nih.gov/pubmed/30895288?tool=bestpractice.com If therapy is initiated, then the catheter should be changed before starting antibiotics.[104]Kranz J, Bartoletti R, Bruyère F, et al. European Association of urology guidelines on urological infections: summary of the 2024 guidelines. Eur Urol. 2024 Jul;86(1):27-41. https://www.sciencedirect.com/science/article/pii/S0302283824022632 http://www.ncbi.nlm.nih.gov/pubmed/38714379?tool=bestpractice.com
Treatment for 7-14 days is generally recommended.[104]Kranz J, Bartoletti R, Bruyère F, et al. European Association of urology guidelines on urological infections: summary of the 2024 guidelines. Eur Urol. 2024 Jul;86(1):27-41. https://www.sciencedirect.com/science/article/pii/S0302283824022632 http://www.ncbi.nlm.nih.gov/pubmed/38714379?tool=bestpractice.com
Primary options
ceftriaxone: 1-2 g intravenously every 24 hours
OR
ampicillin: 2 g intravenously every 6 hours
and
gentamicin: 1.5 mg/kg intravenously every 8 hours
OR
gentamicin: 1.5 mg/kg intravenously every 8 hours
OR
imipenem/cilastatin: 500 mg intravenously every 6-8 hours
More imipenem/cilastatinDose refers to imipenem component.
OR
aztreonam: 1 g intravenously every 8 hours
OR
piperacillin/tazobactam: 3.375 g intravenously every 6 hours
More piperacillin/tazobactamDose consists of 3 g of piperacillin plus 0.375 g of tazobactam.
OR
meropenem/vaborbactam: 4g intravenously every 8 hours
More meropenem/vaborbactamDose consists of 2 g of meropenem plus 2 g of vaborbactam.
OR
plazomicin: 15 mg/kg intravenously every 24 hours, maximum 7 days treatment
OR
cefiderocol: 2 g intravenously every 8 hours
OR
imipenem/cilastatin/relebactam: 1.25 g intravenously every 6 hours
More imipenem/cilastatin/relebactamDose consists of 500 mg of imipenem plus 500 mg of cilastatin plus 250 mg of relebactam.
OR
levofloxacin: 750 mg intravenously every 24 hours
OR
ciprofloxacin: 400 mg intravenously every 12 hours
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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