Urinary Tract Infection in Males Medication
- Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD more...
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP).
The data from GISP showed that the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) had reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125mg IM once as a single dose).
Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. If acute prostatitis or epididymitis is not likely to be caused by gonorrhea, fluoroquinolones may be considered as an option. For more information, see the CDC’s Websites for Antibiotic-Resistant Gonorrhea and CDC Updated recommended treatment regimens for gonococcal infections and associated conditions (April 2007).
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ciprofloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-resistant S aureus (MRSA), S epidermidis, and most gram-negative organisms, but it has no activity against anaerobes. This agent inhibits bacterial deoxyribonucleic acid (DNA) synthesis and growth. Ciprofloxacin is indicated for urinary tract infections (UTIs) and chronic bacterial prostatitis.
Levofloxacin is a fluoroquinolone with better gram-positive activity but less activity against Pseudomonas aeruginosa than ciprofloxacin. This agent is an active L-isomer of ofloxacin. Ciprofloxacin is indicated for complicated and uncomplicated urinary tract infections. It is also used for the treatment of chronic bacterial prostatitis.
Ofloxacin is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. In adults aged 18 years or older, the dosing regimen is by the oral or intravenous (PO/IV) route 200-400mg twice daily (bid). Ofloxacin is FDA approved for the treatment of prostatitis due to E coli.
Norfloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms but no activity against anaerobes. It inhibits bacterial DNA synthesis and, consequently, growth. Norfloxacin is indicated for prostatitis due to E coli and UTIs.
Trimethoprim is a dihydrofolate reductase inhibitor that prevents tetrahydrofolic acid production in bacteria. This agent is active in vitro against a broad range of gram-positive and gram-negative bacteria, including uropathogens such as Enterobacteriaceae and Staphylococcus saprophyticus. Resistance is usually mediated by decreased cell permeability or alterations in the amount or structure of dihydrofolate reductase.
Trimethoprim also demonstrates synergy with sulfonamides, potentiating the inhibition of bacterial tetrahydrofolate production.
Trimethoprim-sulfamethoxazole (TMP-SMZ) is a combination antimicrobial agent designed to take advantage of synergy between TMP and sulfonamides. The antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.
SMZ inhibits dihydropteroate synthetase, preventing incorporation of para-aminobenzoic acid (PABA) into dihydrofolate and subsequent synthesis of tetrahydrofolate. This agent has broad bacteriostatic activity against aerobic gram-positive and gram-negative organisms, with little activity against anaerobes; unfortunately, SMZ does not penetrate well into the kidney.
Ampicillin is an aminopenicillin beta lactam that impairs cell wall synthesis in actively dividing bacteria by binding to and inhibiting penicillin-binding proteins in the cell wall. This agent has enhanced activity against anaerobes and gram-negative aerobes and is generally used in combination with an aminoglycoside for empiric or directed activity against E faecalis urinary tract infections (UTIs).
Amoxicillin is a penicillin antibiotic that interferes with the synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Gentamicin is a bactericidal aminoglycoside antibiotic that inhibits bacterial protein synthesis by binding to the ribosome. This agent has activity against a variety of aerobic gram-negative bacteria, as well as E faecalis and staphylococcal species, and it is used with or without ampicillin to treat acute prostatitis in the hospitalized patient when Enterococcus is a concern. Gentamicin is the only aminoglycoside with appreciable activity against gram-positive organisms.
The dosing regimens for gentamicin are numerous. Adjust the dose based on creatinine clearance (CrCl) and changes in the volume of distribution. Ideal body weight (IBW) should be used for calculations (the drug is not fat soluble).
Trough serum levels should be monitored to ensure adequate clearance and reduce toxicity (< 2 mcg/mL). Peak levels should also be monitored after 4-5 half-lives when it is dosed more often than once daily (qd).
Once-daily dosing should only be used when treating gram-negative infections, as this takes advantage of its concentration-dependent killing and its postantibiotic effect. However, gentamicin exhibits neither of these properties against gram-positive infections. (For synergy against gram-positive organisms, use 1 mg/kg q8h).
Ceftriaxone is a third-generation cephalosporin that has a broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more penicillin-binding proteins, this agent arrests bacterial cell wall synthesis and inhibits bacterial growth.
Ceftazidime is a third generation cephalosporin and a bactericidal agent that exerts its effect by inhibiting the enzymes responsible for cell wall synthesis. Caution should be used with this agent, as nephrotoxicity has been reported following concomitant administration of cephalosporins with aminoglycoside antibiotics or potent diuretics such as furosemide.
In addition, chloramphenicol has been demonstrated to be antagonistic to beta-lactam antibiotics, including ceftazidime, based on in vitro studies and time kill curves with enteric gram-negative bacilli. Because of the possibility of antagonism in vivo, particularly when bactericidal activity is desired, avoid this drug combination.
Tobramycin is an aminoglycoside used for gram-negative bacterial coverage, with better pseudomonal coverage than gentamicin. This agent is commonly used in combination with agents against gram-positive organisms and those that cover anaerobes.
Consider using tobramycin when penicillins or other less-toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms. Its dosing regimens are numerous and are adjusted based on the CrCl and changes in the volume of distribution.
Erythromycin is a macrolide antibiotic that inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used for the treatment of staphylococcal and streptococcal infections.
Vancomycin is a potent antibiotic directed against gram-positive organisms and active against Enterococcus species. It is indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or who have infections with resistant staphylococci. It is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
Doxycycline is a broad-spectrum, bacteriostatic antibiotic in the tetracycline class. It inhibits protein synthesis and, thus, bacterial growth by binding to the 30S and, possibly, the 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Ertapenem has bactericidal activity from inhibition of cell wall synthesis, which is mediated through ertapenem binding to penicillin-binding proteins. This agent is stable against hydrolysis by a variety of beta lactamases, including penicillinases, cephalosporinases, and extended-spectrum beta lactamases. Ertapenem is hydrolyzed by metallo–beta lactamases.
Aztreonam is a monobactam that inhibits cell wall synthesis during bacterial growth. It is active against gram-negative bacilli but has very limited gram-positive activity and is not useful against anaerobes. It lacks cross sensitivity with beta-lactam antibiotics, and it may be used in patients allergic to penicillins or cephalosporins.
Nitrofurantoin is a bactericidal antibiotic indicated for acute cystitis and UTIs caused by E coli, enterococci, S aureus, and strains of Klebsiella and Enterobacter species.
Rifampin is an antituberculosis agent that inhibits RNA synthesis in bacteria by binding to the beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.
Urinary analgesics, such as phenazopyridine, can help to treat the symptoms of dysuria.
Phenazopyridine is compatible with antibacterial therapy and can help to relieve pain and discomfort before antibacterial therapy controls infection. It is used for symptomatic relief of pain, burning, urgency, frequency, and other discomfort arising from irritation of the lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or passage of sounds or catheters. The analgesic action may reduce or eliminate the need for systemic analgesics or narcotics.
Doluoglu OG, Gokkaya CS, Aktas BK, et al. Impact of asymptomatic prostatitis on re-operations due to urethral stricture or bladder neck contracture developed after TUR-P. Int Urol Nephrol. 2012 Jan 18. [Medline].
van der Starre WE, van Nieuwkoop C, Paltansing S, et al. Risk factors for fluoroquinolone-resistant Escherichia coli in adults with community-onset febrile urinary tract infection. J Antimicrob Chemother. 2011 Mar. 66(3):650-6. [Medline].
Meares EM, Stamey TA. Bacteriologic localization patterns in bacterial prostatitis and urethritis. Invest Urol. 1968 Mar. 5(5):492-518. [Medline].
Chung SD, Keller JJ, Lin HC. A case-control study of chronic prostatitis/chronic pelvic pain syndrome and colorectal cancer. BJU Int. 2012 Feb 7. [Medline].
Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002 Jul 8. 113 Suppl 1A:5S-13S. [Medline].
Johnson JR. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004 Sep 15. 39(6):873; author reply 873-4. [Medline].
Chiang IN, Chang SJ, Pu YS, Huang KH, Yu HJ, Huang CY. Major complications and associated risk factors of transrectal ultrasound guided prostate needle biopsy: a retrospective study of 1875 cases in Taiwan. J Formos Med Assoc. 2007 Nov. 106(11):929-34. [Medline].
Nickel JC. The Pre and Post Massage Test (PPMT): a simple screen for prostatitis. Tech Urol. 1997 Spring. 3(1):38-43. [Medline].
Daunt SW. Accuracy of ultrasonography and plain-film abdominal radiography in the diagnosis of urologic abnormalities in men with urinary tract infection: critically appraised topic. Can Assoc Radiol J. 2004 Feb. 55(1):16-7. [Medline].
Guay DR. Contemporary management of uncomplicated urinary tract infections. Drugs. 2008. 68(9):1169-205. [Medline].
Howes DS, Bogner MP. Urinary tract infections. Tintinalli JE, Kelen GD, Stapczyski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2008.
Talan DA, Krishnadasan A, Abrahamian FM, Stamm WE, Moran GJ. Prevalence and risk factor analysis of trimethoprim-sulfamethoxazole- and fluoroquinolone-resistant Escherichia coli infection among emergency department patients with pyelonephritis. Clin Infect Dis. 2008 Nov 1. 47(9):1150-8. [Medline].
Cunha BA. Antibiotic Essentials. 7th ed. Royal Oak, Mich: Physicians Press.; 2008.
Killgore KM, March KL, Guglielmo BJ. Risk factors for community-acquired ciprofloxacin-resistant Escherichia coli urinary tract infection. Ann Pharmacother. 2004 Jul-Aug. 38(7-8):1148-52. [Medline].
Douglas D. Tadalafil confirmed as helpful in LUTS/BPH. Reuters Health Information. August 20, 2013. Available at http://www.medscape.com/viewarticle/809664. Accessed: August 29, 2013.
Wagenlehner FM, Naber KG. Fluoroquinolone Antimicrobial Agents in the Treatment of Prostatitis and Recurrent Urinary Tract Infections in Men. Curr Infect Dis Rep. 2005 Jan. 7(1):9-16. [Medline].
Wagenlehner FM, Naber KG. Current challenges in the treatment of complicated urinary tract infections and prostatitis. Clin Microbiol Infect. 2006 May. 12 Suppl 3:67-80. [Medline].
Luzzi G. Chronic prostatitis. N Engl J Med. 2007 Jan 25. 356(4):423-4; author reply 424. [Medline].
Wagenlehner FM, Weidner W, Naber KG. Therapy for prostatitis, with emphasis on bacterial prostatitis. Expert Opin Pharmacother. 2007 Aug. 8(11):1667-74. [Medline].
Yoon BI, Kim S, Han DS, et al. Acute bacterial prostatitis: how to prevent and manage chronic infection?. J Infect Chemother. 2012 Jan 5. [Medline].
[Guideline] Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1. 50(5):625-63. [Medline]. [Full Text].
[Guideline] Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010 Apr. 31(4):319-26. [Medline]. [Full Text].
Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998 Sep. 105(3):236-41. [Medline].
[Guideline] CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].
McNaughton Collins M, Fowler FJ Jr, Elliott DB, Albertsen PC, Barry MJ. Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?. Urology. 2000 Mar. 55(3):403-7. [Medline].
Porst H, Oelke M, Goldfischer ER, Cox D, Watts S, Dey D, et al. Efficacy and Safety of Tadalafil 5 mg Once Daily for Lower Urinary Tract Symptoms Suggestive of Benign Prostatic Hyperplasia: Subgroup Analyses of Pooled Data From 4 Multinational, Randomized, Placebo-controlled Clinical Studies. Urology. 2013 Jul 19. [Medline].
Olson PD, Hruska KA, Hunstad DA. Androgens Enhance Male Urinary Tract Infection Severity in a New Model. J Am Soc Nephrol. 2015 Oct 8. [Medline].