Urinary Tract Infection (UTI) in Males Medication

Updated: Jul 19, 2018
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Medication

Medication Summary

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.

Because of antimicrobial-resistant N gonorrhoeae, it is important to carefully review relevant clinical history of the patient and precisely determine the etiology of urinary symptoms in males. If gonorrhea is suspected, a fluoroquinolone antibiotic should not be prescribed because of widespread fluoroquinolone resistance to N gonorrhoeae. Dual therapy with ceftriaxone IM/IV plus azithromycin PO is recommended by the CDC sexually transmitted diseases treatment guidelines. [25]

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ciprofloxacin (Cipro)

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 (Levaquin)

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 (Floxin)

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.

Trimethoprim (Proloprim, Trimpex)

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 (Bactrim, Bactrim DS, Septra, Septra DS)

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 (Omnipen, Polycillin, Principen)

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 (Moxatag, Trimox)

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 (Garamycin, Gentacidin)

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).

Tobramycin (TOBI)

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.

Plazomicin (Zemdri)

Semisynthetic aminoglycoside antibacterial derived from sisomicin. Plazomicin has been engineered to overcome aminoglycoside-modifying enzymes (AMEs), the most common aminoglycoside-resistance mechanism in Enterobacteriaceae, and has in vitro activity against extended-spectrum beta-lactamase–producing, aminoglycoside-resistant, and carbapenem-resistant isolates. It is indicated for complicated urinary tract infections (cUTIs), including pyelonephritis caused by the following susceptible microorganism(s): E coli, K pneumoniae, P mirabilis, and E cloacae. Limited clinical safety and efficacy data are available; therefore, the prescribing information recommends to reserve treatment for use in patients with cUTI who have limited or no alternative treatment options.

Ceftriaxone (Rocephin)

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 (Fortaz, Tazicef)

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.

Erythromycin (Erythrocin, Ery-Tab)

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 (Vancocin, Vibra-Tabs)

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 (Vibramycin, Vibra-Tabs)

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 (Invanz)

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 (Azactam, Cayston)

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 (Macrodantin, Furadantin)

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 (Rifadin)

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.

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Analgesics, Urinary

Class Summary

Urinary analgesics, such as phenazopyridine, can help to treat the symptoms of dysuria.

Phenazopyridine

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.

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