Antibiotic treatment of male urinary tract infections: scientific rationale behind the 2026 SPILF guidelines.

The management of male urinary tract infections (UTIs) has historically been based on a monolithic approach, under which every episode was treated as acute prostatitis, leading to prolonged antibiotic courses. To address rising bacterial resistance and promote antimicrobial stewardship, the French Infectious Diseases Society (SPILF) updated its guidelines in 2026, introducing a stratified management framework. This review outlines the scientific evidence underlying these updated recommendations. A comprehensive review of recent literature, including randomized controlled trials and large-scale retrospective cohorts, was conducted so as to evaluate antibiotic efficacy, resistance patterns, and optimal treatment durations for male cystitis, febrile UTIs (prostatitis/pyelonephritis), and acute epididymo-orchitis. Evidence validates distinguishing male cystitis from febrile UTI. For male cystitis, 7-day regimens using narrow-spectrum oral agents-such as fosfomycin trometamol, nitrofurantoin, or pivmecillinam-achieve satisfactory clinical success with minimal risk of complications. Conversely, febrile UTIs require initial parenteral third-generation cephalosporins or oral fluoroquinolones. For targeted oral step-down therapy in prostatitis, cotrimoxazole is preferred over fluoroquinolones so as to minimize ecological impact, while amoxicillin remains the drug of choice for enterococcal coverage. Although recent data show that seven days can be sufficient for selected bacteremic presentations, to prevent relapses a conventional 14-day duration remains the standard for acute prostatitis. Non-sexually transmitted orchitis and epididymitis require a 10-day course of fluoroquinolones or cotrimoxazole. The 2026 SPILF guidelines represent a paradigm shift toward a tailored, stratified approach.