No Clinical Benefit to Treating Male Urinary Tract Infection Longer Than Seven Days: An Outpatient Database Study

Abstract

Background: The optimal approach for treating outpatient male urinary tract infections (UTIs) is unclear. We studied the current management of male UTI in private outpatient clinics, and we evaluated antibiotic choice, treatment duration, and the outcome of recurrence of UTI.

Methods: Visits for all male patients 18 years of age and older during 2011-2015 with International Classification of Diseases, Ninth Revision, Clinical Modification codes for UTI or associated symptoms were extracted from the EPIC Clarity Database of 2 family medicine, 2 urology, and 1 internal medicine clinics. For eligible visits in which an antibiotic was prescribed, we extracted data on the antibiotic used, treatment duration, recurrent UTI episodes, and patient medical and surgical history.

Results: A total of 637 visits were included for 573 unique patients (mean age 53.7 [±16.7 years]). Fluoroquinolones were the most commonly prescribed antibiotics (69.7%), followed by trimethoprim-sulfamethoxazole (21.2%), nitrofurantoin (5.3%), and beta-lactams (3.8%). Antibiotic choice was not associated with UTI recurrence. In the overall cohort, longer treatment duration was not significantly associated with UTI recurrence (odds ratio [OR] = 1.95; 95% confidence interval [CI], 0.91-4.21). Longer treatment was associated with increased recurrence after excluding men with urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, and benign prostatic hyperplasia (OR = 2.62; 95% CI, 1.04-6.61).

Conclusions: Our study adds evidence that men with UTI without evidence of complicating conditions do not need to be treated for longer than 7 days. Shorter duration of treatment was not associated with increased risk of recurrence. Shorter treatment durations for many infections, including UTI, are becoming more attractive to reduce the risk of resistance, adverse events, and costs.

Keywords: antibacterial agents; antibiotics; resistance; stewardship; urinary tract infections.

Figure 1.

Approach to choosing empirical antibiotic treatment for male urinary tract infections. ¹Avoid if resistance prevalence is known to exceed 20% or if used to treat urinary tract infection in previous 3 months. ²For resistant organisms. Adapted from Schaeffer AJ and Nicolle LE. Clinical practice. Urinary tract infections in older men. N Engl J Med. 2016;374:562.

Figure 2.

Selection process for urinary tract infection (UTI) visits. ¹International Classification of Diseases (ICD-9) codes 595.0 acute cystitis, 595.9 cystitis unspecified, and 599.0 UTI site not specified. ²ICD-9 codes 788.1 dysuria, 788.63 urgency of urination, and 799.41 frequency of urination. ³Six miscellaneous infections, 4 pneumonia, 66 gastrointestinal, 14 mucosal, 8 sinusitis, 3 pharyngitis, 2 otitis, and 1 acne. ⁴Seven visits had active chemotherapy and 7 had active steroid therapy. ⁵Twenty-four visits had code for epididymitis/orchitis, 16 for other disorder of bladder, 17 other disorder of urethra, 103 urethral stricture, 9 unspecified disorder of kidney and urethra, and 8 syphilis. ⁶Four visits were prescribed azithromycin, 1 polymyxin B, 2 ceftriaxone, 1 clarithromycin, and 3 doxycycline.

Figure 3.

Risk of recurrence with longer antibiotic treatment in men with urinary tract infections without predisposing factors. Predisposing factors include anatomic abnormalities, history of urogenital malignancy or surgery, catheterization, or compromised immune status.