What is the recommended antibiotic regimen for the treatment of epididymoorchitis?

Antibiotic Treatment for Epididymoorchitis

For epididymoorchitis, 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

Treatment Algorithm Based on Patient Age and Risk Factors

Sexually Transmitted Epididymoorchitis (Typical in men <35 years)

1. First-line regimen:

   • Ceftriaxone 250 mg IM (single dose) 1
   • PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2

2. Alternative regimen (if cephalosporin allergy):

   • Ofloxacin 300 mg orally twice daily for 10 days 1
   • Note: Contraindicated in patients ≤17 years of age

Enteric Organism Epididymoorchitis (Typical in men >35 years or with urinary tract abnormalities)

1. Recommended regimen:

   • Ofloxacin 300 mg orally twice daily for 10 days 1, 3
   • OR Levofloxacin 500 mg orally daily for 10 days 3

2. Alternative regimen (if fluoroquinolone resistance concerns):

   • Ceftriaxone 250 mg IM (single dose) 1
   • PLUS Levofloxacin or Ofloxacin for 10 days 1, 3

Important Clinical Considerations

Diagnostic Approach

• Obtain Gram-stained smear of urethral exudate for N. gonorrhoeae
• Culture urethral exudate for N. gonorrhoeae
• Test for C. trachomatis
• Culture and Gram-stained smear of urine for Gram-negative bacteria 1
• Consider scrotal ultrasound with Doppler to rule out testicular torsion 1

Follow-up Recommendations

• Re-evaluate within 72 hours after initiating antibiotics to assess clinical improvement 1
• If no improvement occurs within 3 days, consider hospitalization and alternative diagnoses 1
• Persistent swelling or tenderness after completing antimicrobial therapy warrants evaluation for testicular cancer, tuberculosis, or fungal epididymitis 1

Special Populations

• Men who practice insertive anal intercourse: Consider enteric organisms as potential pathogens and treat with ceftriaxone plus levofloxacin or ofloxacin 3
• Immunocompromised patients: Require vigilant monitoring due to increased risk of fungal and mycobacterial causes 1
• Men >35 years: More likely to have epididymitis caused by enteric organisms; evaluate for urinary tract abnormalities or bladder outlet obstruction 1, 4

Supportive Care

• Bed rest until fever and local inflammation subside
• Scrotal elevation
• Adequate analgesics and fluid intake 1
• Application of heat or cold over the perineum may provide symptomatic relief 1

Potential Complications

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 1

The increasing resistance to fluoroquinolones, particularly ciprofloxacin, in E. coli isolates necessitates careful consideration of alternative antimicrobials with adequate penetration into genital tissues, especially for men over 35 years with epididymoorchitis likely caused by enteric organisms 4.