What antibiotics are recommended for the treatment of epididymitis?

Antibiotic Treatment for Epididymitis

For epididymitis, the recommended first-line treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1, 2

Treatment Based on Age and Risk Factors

Men Under 35 Years

• First-line therapy:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice daily for 10 days 1, 3
  • Targets most common pathogens: Neisseria gonorrhoeae and Chlamydia trachomatis

Men Who Practice Insertive Anal Intercourse

• Recommended regimen:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice daily for 10 days 2, 3
  • Covers both STI pathogens and enteric organisms

Men Over 35 Years

• Recommended regimen:
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice daily for 10 days 2, 3
  • Targets enteric bacteria commonly causing epididymitis in older men with urinary tract abnormalities

Diagnostic Considerations

Before initiating treatment, perform:

• Gram-stained smear of urethral exudate for N. gonorrhoeae and non-gonococcal urethritis
• Culture of urethral exudate for N. gonorrhoeae
• Testing for C. trachomatis
• Culture and Gram-stained smear of urine for Gram-negative bacteria 1

Important Clinical Pearls

• Epididymitis must be distinguished from testicular torsion, which is a surgical emergency requiring immediate intervention 2
• In 53% of patients, urethritis may be present without visible discharge, so endourethral smears are essential 4
• Untreated epididymitis can lead to infertility and chronic scrotal pain 3
• Even when cultures are negative, empiric therapy should be initiated based on age and risk factors 1, 3

Follow-up Care

• Patients should have a microbiologic re-examination 7-10 days after completing therapy 1
• Some experts recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after completing therapy 1
• Supportive measures including bed rest, scrotal elevation, analgesics, and adequate fluid intake are essential for managing symptoms 2

Partner Management

• Evaluation and treatment of sex partners is crucial to prevent reinfection
• Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae regardless of the pathogens isolated from the infected man 1

Common Pitfalls to Avoid

• Ciprofloxacin alone is not optimal for treating chlamydial infections, despite being commonly prescribed 5, 6
• Delaying treatment while awaiting culture results can worsen outcomes; empiric therapy should be started promptly 1
• Failure to refer patients to sexual health services for contact tracing can lead to reinfection or continued transmission 5
• Neglecting to consider testicular torsion in the differential diagnosis, especially in adolescents with acute scrotal pain 2

Remember that the choice of antibiotic should target the most likely pathogens based on the patient's age and sexual practices, with prompt initiation of therapy being essential to prevent complications.