What is the next step in managing a 62-year-old male with persistent right epididymitis despite treatment with intramuscular (IM) ceftriaxone and a 10-day course of levofloxacin (levofloxacin)?

From the Guidelines

For a 62-year-old male with right epididymitis not responding to IM ceftriaxone and 10 days of levofloxacin, I recommend obtaining a urine culture and sensitivity test, scrotal ultrasound, and considering alternative antibiotic therapy with trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg twice daily for 14 days or doxycycline 100 mg twice daily for 14 days. The lack of improvement suggests either antibiotic resistance, an abscess requiring drainage, or a non-infectious etiology such as testicular torsion, tumor, or vasculitis 1. According to the European Association of Urology guidelines on urological infections, failure to respond to initial treatment or presence of an abscess necessitates a first voided urine for nucleic acid amplification test (NAAT) and scrotal ultrasound examination 1.

The patient should be referred to urology for further evaluation, particularly if pain is severe or there are concerning ultrasound findings. Pain management with NSAIDs like ibuprofen 600 mg every 6 hours and scrotal support/elevation should be continued. Persistent epididymitis in older men warrants investigation for underlying structural abnormalities of the urinary tract or prostate issues. If symptoms worsen (increasing pain, fever, scrotal swelling), immediate medical attention is necessary as surgical intervention may be required. Treatment failure after two antibiotic regimens raises concern for resistant organisms or complications that require specialist management. Key considerations in the management of this patient include:

• Reevaluation of the diagnosis and therapy, as suggested by the Centers for Disease Control and Prevention 1
• Comprehensive evaluation of swelling and tenderness that persist after completion of antimicrobial therapy, including consideration of tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis 1
• Clinical assessment and consideration of parenteral therapy if severe infection is suspected 1

From the Research

Next Steps in Managing Epididymitis

The patient in question is a 62-year-old male with persistent right epididymitis despite treatment with intramuscular (IM) ceftriaxone and a 10-day course of levofloxacin. Given his age and the fact that the initial treatment did not resolve the condition, the next steps should consider the likely causative organisms and the patient's specific situation.

Consideration of Causative Organisms

• In men older than 35 years, epididymitis is usually caused by enteric bacteria transported by reflux of urine into the ejaculatory ducts secondary to bladder outlet obstruction 2.
• The most common bacteria found in urine cultures of men with epididymitis are Escherichia coli (E. coli), followed by other organisms like Streptococcus, Klebsiella, Pseudomonas, and Serratia 3.

Treatment Approach

• For men older than 35 years, levofloxacin or ofloxacin alone is often sufficient to treat epididymitis caused by enteric bacteria 2.
• Given the patient's age and the failure of initial treatment with ceftriaxone and levofloxacin, further investigation into the causative organism may be necessary, potentially through urine culture or other diagnostic means.
• If the patient has not undergone a urine culture, this could be a crucial next step to identify the specific bacteria causing the infection and guide further antibiotic treatment 3.

Additional Considerations

• The patient's symptoms and response to initial treatment should be reassessed to determine if additional diagnostic tests, such as imaging studies, are needed to rule out other conditions or complications.
• Given that untreated acute epididymitis can lead to infertility and chronic scrotal pain, prompt and effective treatment is vital 2, 3.

Potential Next Steps

• Re-evaluate the patient's symptoms and consider additional diagnostic tests to guide further treatment.
• If not already done, obtain a urine culture to identify the causative organism and adjust antibiotic treatment accordingly.
• Consider consulting a urologist for further evaluation and management, especially if the patient's condition does not improve with antibiotic treatment or if complications are suspected.