What antibiotics are used to treat epididymitis?

Antibiotic Treatment for Epididymitis

Age-Based Treatment Algorithm

The choice of antibiotics for epididymitis depends primarily on patient age, with men under 35 years requiring coverage for sexually transmitted organisms (N. gonorrhoeae and C. trachomatis), while men over 35 years need coverage for enteric organisms.

For Men Under 35 Years Old (Sexually Active)

Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days is the recommended first-line regimen 1, 2. This combination targets the most common pathogens in this age group: N. gonorrhoeae and C. trachomatis 3, 4.

• The ceftriaxone provides immediate coverage for gonorrhea, while doxycycline addresses chlamydia, which is a dominant cause of acute epididymitis in younger men 4
• Treatment duration of 10 days is critical to prevent complications including infertility and chronic scrotal pain 3
• This regimen achieves microbiologic cure, improves symptoms, prevents transmission, and decreases complications 1

For Men Over 35 Years Old

Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days is the preferred treatment 1, 2.

• These fluoroquinolones provide adequate coverage for enteric organisms (primarily E. coli) that cause epididymitis in this age group, typically secondary to bladder outlet obstruction or benign prostatic hyperplasia 3, 5
• Fluoroquinolones are also appropriate for patients allergic to cephalosporins and/or tetracyclines 1

Special Population: Men Who Practice Insertive Anal Intercourse

Ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg orally twice daily for 10 days) should be used 3.

• This regimen covers both sexually transmitted organisms and enteric pathogens that are more likely in this population 3

Important Clinical Caveats

Reevaluation Threshold

• Failure to improve within 3 days requires immediate reevaluation of both diagnosis and therapy 1, 2
• Consider alternative diagnoses including testicular torsion (surgical emergency), tumor, abscess, infarction, testicular cancer, tuberculosis, or fungal epididymitis 1, 2

Testicular Torsion Warning

• Testicular torsion must be considered in all cases, especially in adolescents and when pain onset is sudden or severe 1, 2
• Emergency surgical consultation is required if diagnosis is questionable, as testicular viability may be compromised 1

Adjunctive Therapy

• Bed rest, scrotal elevation, and analgesics should be prescribed until fever and local inflammation subside 1, 2

Partner Management

• Sexual partners who had contact within 60 days preceding symptom onset must be evaluated and treated if N. gonorrhoeae or C. trachomatis is confirmed or suspected 1, 2
• Patients should abstain from sexual intercourse until both they and their partners complete therapy and are asymptomatic 1

HIV-Infected Patients

• HIV-positive patients with uncomplicated epididymitis receive the same treatment regimens as HIV-negative patients 1, 2
• However, immunosuppressed patients are more susceptible to fungal and mycobacterial causes of epididymitis 1, 2

Hospitalization Considerations

• Consider admission when severe pain suggests alternative diagnoses (torsion, abscess, infarction), when patients are febrile, or when compliance with outpatient therapy is questionable 1, 2

Emerging Resistance Concerns

While fluoroquinolones remain guideline-recommended for men over 35, rising ciprofloxacin resistance in E. coli isolates is creating challenges for future treatment of enteric organism-associated epididymitis 5. Despite this concern, levofloxacin and ofloxacin remain the current standard of care for this population 1, 2.