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.[44]
Men with a positive U/A by dipstick or microscopic exam and specific symptoms (dysuria, frequency, urgency, suprapubic pain, or costovertebral angle pain) should receive empiric 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) 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.[4][Evidence A][Evidence C] If therapy is initiated, then the catheter should be changed before starting antibiotics.[29]
Intravenous therapy and hospitalization are indicated for patients who are severely ill, such as in cases of suspected bacteremia.[44] Intravenous therapy is continued until the patient is stabilized and afebrile. Oral antibiotic therapy using fluoroquinolones may be considered as an alternative to intravenous because of excellent bioavailability. Illness severity is judged by the presence of a generally toxic-appearing patient, with fever, tachycardia, tachypnea, hypotension, or an elevated white blood cell count. The decision to hospitalize 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 hospitalization.
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. Treatment options include beta-lactam antibiotics (often in combination with other antibiotics [e.g., aminoglycosides]), trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, and fluoroquinolones.[10][44]
The choice of initial empiric therapy should be guided by local resistance patterns.[44] All men should have a urine culture to assure that the initial empiric 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.
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.[3][6][11][12][13][14][21][25][56] 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, the Infectious Diseases Society of America guidelines for using trimethoprim/sulfamethoxazole (TMP/SMX) as first-line empiric therapy for UTI in women may not apply to men.[57] Furthermore, this recommendation suggests using TMP/SMX first-line only if local E coli resistance patterns are less than 20%, and US data suggest TMP/SMX resistance ranges between 18% and 22%.[56] This phenomenon is not just localized to the US; a trial involving men in German outpatient settings noted 34% resistance to TMP/SMX.[14] Risk factors identified for having an infection resistant to TMP/SMX include recent use of TMP/SMX or any antibiotic and recent hospitalization.[58]
Trials to determine antibiotic choice for treating UTI in men are sparse. The few available trials involving use of TMP/SMX in men suggest poor success. A small study of men with recurrent UTI compared 10 days of TMP/SMX with 12 weeks of therapy; microbiologic cure occurred in 3 out of 15 and 9 out of 15, respectively.[59]
In contrast, the fluoroquinolones perform better in head-to-head comparison and in length of therapy required for microbiologic cure.
One study involving both men and women with complicated UTI resulted in cure rates of 95% and 43% for lomefloxacin and TMP/SMX, respectively.[60]
In another study, 2 weeks of ciprofloxacin in men with febrile UTI compared favorably with 4 weeks of therapy.[21]
However, fluoroquinolones have been associated with serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[61] Warnings have also been issued about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[62][63]
Depending on patient characteristics and local resistance patterns, fluoroquinolone antibiotics remain a reasonable first-line treatment of UTI in men due to the higher risk of a complicated course in this patient group.[44]
Due to high levels of resistance, the European Association of Urology recommends against the use of fluoroquinolones for the empiric treatment of complicated UTI in patients from urology departments or when patients have used fluoroquinolones in the last 6 months.[44]
TMP/SMX may be considered first-line in younger men without evidence of complicated UTI and with consideration to local resistance patterns.
Of note, oral antibiotic therapy, and specifically ciprofloxacin, compared favorably with intravenous ciprofloxacin in a trial of 141 patients with pyelonephritis, community-acquired UTI, or hospital-acquired UTI.[64][65]
In the setting of increasing drug resistance in uropathogens, the following treatments are approved by the Food and Drug Administration for use in adults with complicated UTI caused by susceptible organisms who have limited or no alternative options: meropenem/vaborbactam, plazomicin, cefiderocol, and imipenem/cilastatin/relebactam.[66][67][68][69][70]
Length of therapy
Complicated infections require longer therapy. Most authorities recommend a minimum of 14 days in patients with complicated UTI, and men often have complicated UTI.[11][44][71] Furthermore, the incidence of UTI in men is related to aging, and a minimum of 14 days of therapy corresponds to recommendations for geriatric patients.[11] Data suggest a shorter course option specifically for higher dose levofloxacin in complicated UTI; however, only approximately one third of the study subjects were male.[72]
In younger men, complicated infections occur less frequently. They may also have a clearly identifiable risk for UTI, such as sexual activity. In such cases, 7 days of therapy may be adequate.
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 perirenal abscess requiring surgical drainage. Urology consultation should be considered for men with treatment failure.
After completing acute UTI treatment, men should have clinical follow-up within 2 to 4 weeks. During this visit, further testing is not required, but the physician should ensure resolution of symptoms and completion of antibiotic therapy, and seek to identify factors that may indicate complicated UTI. 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.[4] However, before a urologic procedure that may disrupt the urinary tract lining, an attempt should be made to sterilize the urine to decrease the risk of bacteremia and sepsis. The optimal choice of antibiotics, and timing and duration of therapy, have not been well defined by clinical trials. However, treatment should occur before urologic procedures.
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