What oral antibiotic can be prescribed for an 86-year-old male with left epididymitis, penicillin (PCN) allergy, and impaired renal function, as an alternative to Levofloxacin (levofloxacin) due to risk of arrhythmias with his current medications, including Rapaflo (silodosin) and Eliquis (apixaban)?

Antibiotic Treatment for Epididymitis in an 86-Year-Old Male with PCN Allergy

Trimethoprim-sulfamethoxazole (TMP-SMX) is the most appropriate oral antibiotic for this 86-year-old male with left epididymitis, penicillin allergy, and impaired renal function, as it provides effective coverage against enteric organisms commonly causing epididymitis in older men while avoiding the arrhythmia risks associated with fluoroquinolones.

Patient Assessment and Etiology

This patient presents with several key factors that influence antibiotic selection:

• 86-year-old male with BPH and bladder stones
• Left epididymitis confirmed by ultrasound
• Penicillin allergy (rash)
• Impaired renal function (SrCr 1.29)
• Current medications including Rapaflo (silodosin) and Eliquis (apixaban)
• Contraindication to levofloxacin due to arrhythmia risk

In men older than 35 years, epididymitis is typically caused by enteric organisms rather than sexually transmitted infections. This is particularly true in patients with:

• BPH causing bladder outlet obstruction
• History of bladder stones
• Recent urinary tract instrumentation (like prostate biopsy) 1

Antibiotic Selection Algorithm

1. First choice: Trimethoprim-sulfamethoxazole (TMP-SMX)

   • Dosing: DS tablet (160/800 mg) twice daily for 10 days
   • Adjust dose for renal impairment: Consider DS tablet once daily if CrCl < 30 mL/min
   • Provides good coverage against common enteric pathogens
   • Avoids the arrhythmia risks of fluoroquinolones
   • No significant interaction with Eliquis or Rapaflo

2. Alternative if TMP-SMX contraindicated:

   • Azithromycin 500 mg on day 1, then 250 mg daily for 4 days 2
   • Less ideal coverage for enteric organisms but safer cardiac profile
   • Minimal renal adjustment needed

3. If treatment fails after 3 days:

   • Reevaluate diagnosis and consider urology consultation
   • Consider parenteral therapy with ceftriaxone (if cephalosporin allergy not present)

Rationale for Avoiding Fluoroquinolones

While the CDC guidelines mention ofloxacin for epididymitis caused by enteric organisms 3, fluoroquinolones (including levofloxacin and ofloxacin) should be avoided in this patient due to:

1. Risk of QT prolongation and arrhythmias, especially concerning with concomitant medications
2. FDA black box warnings for tendon rupture (higher risk in elderly patients)
3. Increased risk of aortic aneurysm/dissection in elderly patients
4. Growing resistance among enteric organisms 4

Supportive Measures

In addition to antibiotic therapy, recommend:

• Bed rest until acute symptoms improve
• Scrotal elevation
• Analgesics for pain control
• Warm compresses to affected area

Follow-Up Recommendations

• Clinical reassessment within 3 days to evaluate treatment response
• If no improvement after 3 days, consider alternative diagnoses including:
  • Testicular abscess
  • Testicular tumor
  • Infarction
  • Tuberculous or fungal epididymitis 3

Special Considerations for This Patient

• Monitor renal function during treatment
• Evaluate for potential drug interactions with current medications
• Consider the patient's age and comorbidities when selecting antibiotic therapy
• Address underlying BPH and bladder stones to prevent recurrence

If the patient shows signs of systemic infection (high fever, severe pain) or fails to respond to oral therapy, hospitalization and parenteral antibiotics should be considered.