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

Antibiotic Regimen for Epididymitis

For epididymitis, the recommended antibiotic regimen is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days in sexually active men under 35 years, while men over 35 or those with enteric infections should receive a fluoroquinolone (ofloxacin 300 mg orally twice daily or levofloxacin 500 mg orally once daily) for 10 days. 1

Treatment Based on Patient Age and Likely Pathogens

For men under 35 years (sexually transmitted pathogens):

• First-line therapy:
  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 10 days 1
• Target organisms: Neisseria gonorrhoeae and Chlamydia trachomatis 2
• For men who practice insertive anal intercourse:
  • Consider coverage for enteric organisms with ceftriaxone plus either levofloxacin or ofloxacin 1, 2

For men over 35 years (enteric pathogens):

• First-line therapy:
  • Ofloxacin 300 mg orally twice a day for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1
• Target organisms: Primarily Escherichia coli and other enteric bacteria 2, 3
• Evidence of efficacy: Fluoroquinolones have demonstrated superior efficacy compared to other antibiotics like pivampicillin, with treatment failure rates of 20% vs 40% respectively 4, 5

Diagnostic Considerations

Before initiating treatment, obtain:

1. Gram-stained smear of urethral exudate for diagnosis of urethritis
2. Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
3. Urinalysis and urine culture to identify enteric organisms
4. Syphilis serology and HIV testing 1

Adjunctive Therapy

In addition to antibiotics, recommend:

• Bed rest
• Scrotal elevation
• Analgesics until fever and local inflammation subside 1

Follow-Up Recommendations

• If no improvement within 3 days, reevaluate both diagnosis and therapy
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation
• Consider alternative diagnoses: tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1

Management of Sexual Partners

• For cases caused by STIs, refer sexual partners for evaluation and treatment
• Partners should be evaluated if contact occurred within 60 days before symptom onset
• Advise abstinence from sexual intercourse until both patient and partner(s) complete treatment and are asymptomatic 1

Special Considerations

• HIV-infected patients: Same treatment regimen as HIV-negative patients
• Caution: Fungi and mycobacteria are more common causes in immunosuppressed patients 1
• Pitfall to avoid: Using ciprofloxacin alone for young men, as it's not optimal for chlamydial infections 6
• Doxycycline administration: Take with food or milk if gastric irritation occurs; ensure adequate fluid intake to reduce risk of esophageal irritation 7

Remember that prompt and appropriate antibiotic therapy is essential to prevent complications such as infertility and chronic scrotal pain 2.