Should a 45-year-old patient with epididymitis, who has been on doxycycline (doxy) for 1 week, be switched to a fluoroquinolone (FQ) for 1 week due to persistent diffuse abdominal pain, bloating, and soft kidneys, with a negative kidney, ureter, and bladder (KUB) test?

Management of Epididymitis with Gastrointestinal Symptoms

For a 45-year-old patient with epididymitis on doxycycline for 1 week who is now experiencing diffuse abdominal pain and bloating, switching to a fluoroquinolone (levofloxacin or ofloxacin) for 1 week is recommended.

Evaluation of Current Symptoms

The patient's presentation suggests:

• Epididymitis treated with doxycycline for 1 week
• Development of gastrointestinal side effects (diffuse abdominal pain, bloating)
• Soft physical exam findings
• Negative KUB (kidney, ureter, bladder) radiograph

Treatment Recommendations

First-line Treatment Adjustment

1. Switch to fluoroquinolone therapy:

   • Levofloxacin 500 mg orally once daily for 10 days 1, 2
   • OR
   • Ofloxacin 300 mg orally twice daily for 10 days 1, 2

2. Rationale for switching:

   • Gastrointestinal symptoms are common side effects of doxycycline
   • Fluoroquinolones are effective alternative regimens for epididymitis 2
   • In men over 35 years, enteric organisms are more likely causative agents 3, 4

Alternative Options (if fluoroquinolones are contraindicated)

• Azithromycin 1 g orally in a single dose 2
• OR
• Erythromycin base 500 mg orally four times daily for 7-14 days 1, 2
• OR
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7-14 days 1, 2

Age-Specific Considerations

For patients over 35 years (like this 45-year-old):

• Epididymitis is typically caused by enteric bacteria rather than STIs 3, 4
• These infections often result from reflux of urine into ejaculatory ducts due to bladder outlet obstruction 3
• Fluoroquinolones have traditionally been the treatment of choice for this age group 3, 4

Monitoring and Follow-up

• Clinical improvement should occur within 3 days of starting the new treatment 2
• If no improvement is seen, reevaluate diagnosis and therapy 2
• Continue supportive measures:
  • Bed rest
  • Scrotal elevation
  • NSAIDs for pain management 2

Potential Complications to Monitor

• Abscess formation
• Testicular ischemia
• Infertility
• Chronic scrotal pain 2

Special Considerations

Fluoroquinolone Safety

• Fluoroquinolones carry risks including:
  • QTc prolongation
  • Tendon rupture (especially in elderly)
  • Neuropsychiatric disturbances
  • Hypoglycemia 1, 5

Antimicrobial Resistance

• Rising resistance to ciprofloxacin in E. coli isolates has been reported 4
• Consider local resistance patterns when selecting therapy

Conclusion

The patient's gastrointestinal symptoms are likely related to doxycycline therapy. Given his age (45 years), switching to a fluoroquinolone (levofloxacin or ofloxacin) is appropriate as these medications:

1. Are effective against likely causative organisms in his age group
2. May be better tolerated than doxycycline
3. Are recommended alternative regimens in treatment guidelines

If symptoms persist after switching antibiotics, further diagnostic evaluation would be warranted.