What is the recommended antibiotic treatment for epididymitis?

Antibiotic Treatment for Epididymitis

For epididymitis most likely caused by gonococcal or chlamydial infection (men <35 years), the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 10 days. 1

Treatment Algorithm Based on Patient Age and Risk Factors

For Men Under 35 Years (Sexually Transmitted Pathogens)

• First-line regimen:

  • Ceftriaxone 250 mg IM in a single dose, PLUS
  • Doxycycline 100 mg orally twice a day for 10 days 1, 2

• This combination targets the most common pathogens in this age group: Neisseria gonorrhoeae and Chlamydia trachomatis, which account for approximately 78% of cases in young men 3

For Men Who Practice Insertive Anal Intercourse

• Modified regimen for enteric organisms:
  • Ceftriaxone 250 mg IM in a single dose, PLUS
  • Levofloxacin 500 mg orally once daily for 10 days OR
  • Ofloxacin 300 mg orally twice a day for 10 days 1, 4

For Men Over 35 Years (Enteric Organisms)

• Recommended regimen:

  • Ofloxacin 300 mg orally twice a day for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

• This targets enteric bacteria (commonly E. coli) which are more prevalent in older men with urinary tract abnormalities or recent instrumentation 4, 5

For Patients with Allergies

• For patients allergic to cephalosporins and/or tetracyclines:
  • Ofloxacin 300 mg orally twice a day for 10 days OR
  • Levofloxacin 500 mg orally once daily for 10 days 1

Diagnostic Considerations

Proper diagnosis is crucial before initiating treatment:

1. Urethral evaluation:

   • Gram-stained smear of urethral exudate for diagnosis of urethritis
   • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis

2. Urine studies:

   • Examination of first-void urine for leukocytes if urethral Gram stain is negative
   • Culture and Gram-stained smear of uncentrifuged urine

3. Additional testing:

   • Syphilis serology and HIV counseling/testing 1

Adjunctive Therapy

In addition to antibiotics, the following supportive measures are recommended:

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

Follow-Up Recommendations

• Patients should be reevaluated if symptoms do not improve within 3 days
• Persistent swelling or tenderness after completing antibiotics requires comprehensive evaluation for other conditions (tumor, abscess, infarction, testicular cancer, TB, fungal epididymitis) 1

Management of Sexual Partners

• Sexual partners should be referred for evaluation and treatment if contact occurred within 60 days preceding symptom onset
• Patients should avoid sexual intercourse until they and their partners complete treatment and are symptom-free 1

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis and HIV should receive the same treatment regimen as HIV-negative patients
• Be aware that fungi and mycobacteria are more likely causes in immunosuppressed patients 1

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to differentiate epididymitis from testicular torsion, which is a surgical emergency
2. Inappropriate antibiotic selection: Using ciprofloxacin alone for young men, which is not optimal for chlamydial infections 6
3. Inadequate partner management: Not referring patients for contact tracing and partner treatment
4. Delayed follow-up: Not reevaluating patients who fail to improve within 3 days

Remember that untreated acute epididymitis can lead to serious complications including infertility and chronic scrotal pain, making prompt and appropriate antibiotic therapy essential 4.