What is the recommended treatment duration for Brucella orchitis?

Treatment Duration for Brucella Orchitis

The optimal treatment for Brucella orchitis consists of doxycycline 100 mg twice daily for 6 weeks combined with either streptomycin 15 mg/kg daily intramuscularly for 2-3 weeks or rifampicin 600-900 mg daily for 6 weeks. 1

First-Line Treatment Options

The treatment of Brucella orchitis follows the same principles as general brucellosis treatment, with specific considerations for this genitourinary complication. Based on the Ioannina recommendations, the following regimens are recommended:

Preferred Regimens (Category AI evidence):

1. Doxycycline-Streptomycin (DOX-STR)

   • Doxycycline: 100 mg twice daily orally for 6 weeks
   • Streptomycin: 15 mg/kg daily intramuscularly for 2-3 weeks

2. Doxycycline-Rifampicin (DOX-RIF)

   • Doxycycline: 100 mg twice daily orally for 6 weeks
   • Rifampicin: 600-900 mg daily for 6 weeks (as a single morning dose)

Alternative Regimen (Category BI evidence):

• Doxycycline-Gentamicin (DOX-GENT)
  • Doxycycline: 100 mg twice daily orally for 6 weeks
  • Gentamicin: 5 mg/kg daily parenterally in 1 dose for 7 days

Efficacy Considerations

The DOX-STR regimen appears to be superior for orchitis specifically. In a study of 48 patients with Brucella epididymo-orchitis, the failure/relapse rate was significantly lower in the doxycycline-streptomycin group (7.1%) compared to the doxycycline-rifampicin group (20%) 2. This suggests that for this specific complication, the aminoglycoside-containing regimen may be preferable.

The duration of treatment is critical for preventing relapse. Short-term treatment regimens (less than 4 weeks) have been associated with significantly higher relapse rates (22%) compared to standard duration treatments (4.8%) 3. This underscores the importance of completing the full 6-week course of doxycycline.

Treatment Algorithm

1. Confirm diagnosis: Positive blood/urine cultures for Brucella and/or positive serology with clinical signs of orchitis
2. First choice: Doxycycline-streptomycin regimen for uncomplicated cases
3. Alternative if streptomycin unavailable: Doxycycline-gentamicin regimen
4. If parenteral therapy not feasible: Doxycycline-rifampicin regimen

Special Considerations

• Conservative management is generally adequate for Brucella orchitis, and surgical intervention (orchiectomy) is rarely required 2
• Supportive measures such as analgesics or ice bags may help manage testicular pain and swelling 4
• Monitor for relapse after treatment completion, particularly in patients treated with regimens other than doxycycline-streptomycin
• Reproductive function may be temporarily affected during the course of the disease but typically resolves with appropriate treatment 4

Common Pitfalls

1. Misdiagnosis: Brucella orchitis is often misdiagnosed in the early stages, particularly in non-endemic areas. Consider this diagnosis in patients with testicular pain/swelling and systemic symptoms, especially with relevant epidemiological history.

2. Inadequate treatment duration: Shorter treatment courses lead to significantly higher relapse rates. The full 6-week course of doxycycline is essential.

3. Unnecessary surgery: Conservative antibiotic management is typically sufficient, and orchiectomy should be avoided 2.

4. Delayed diagnosis: The average duration of symptoms before diagnosis can be substantial (52.5 ± 70 days in one study) 2, highlighting the need for increased awareness of this condition.

In conclusion, while treatment approaches for brucellosis have remained relatively stable over decades, the evidence supports a 6-week regimen of doxycycline combined with either streptomycin (2-3 weeks) or rifampicin (6 weeks) for Brucella orchitis, with the doxycycline-streptomycin combination showing superior outcomes specifically for this complication.