Should an infant with orchitis be treated with antibiotics or steroids?

Treatment of Orchitis in Infants

In infants with orchitis, antibiotics should be given only after determining the underlying etiology, as most cases in prepubertal children are viral (not requiring antibiotics) or related to anatomical abnormalities, while steroids have no proven role in treatment.

Diagnostic Approach and Etiology Determination

The critical first step is identifying whether the orchitis is bacterial, viral, or inflammatory in nature, as this fundamentally changes management:

• Obtain urine culture in all cases to identify bacterial pathogens, as only 4.1% of pediatric epididymo-orchitis cases have positive urine cultures, making empiric antibiotics often unnecessary 1
• Evaluate for sexually transmitted infections if there is any concern for gonococcal infection, using only standard culture procedures (not Gram stains or non-culture tests alone) due to legal implications in children 2
• Consider viral etiologies first in prepubertal children, as mumps orchitis and other viral causes are common and do not respond to antibiotics 3

When to Use Antibiotics

Antibiotics are indicated only in specific circumstances:

• Young infants (under 3 months) should receive empiric antibiotics due to higher risk of bacterial infection and potential for serious complications 1
• Presence of pyuria on urinalysis warrants antibiotic therapy while awaiting culture results 1
• Positive urine culture requires targeted antibiotic therapy based on sensitivities, noting that organisms may not be sensitive to usual empiric therapy 1
• Confirmed gonococcal infection requires ceftriaxone 125 mg IM as a single dose for infants weighing <45 kg, with evaluation for disseminated infection including sepsis, arthritis, and meningitis 2

Antibiotic Selection When Indicated

• For bacterial orchitis with positive cultures, treatment should be guided by culture sensitivities rather than empiric fluoroquinolones 1
• For gonococcal orchitis with complications (bacteremia, arthritis), use ceftriaxone 50 mg/kg/day IV or IM for 7 days, or cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days 2
• Duration of therapy should be 7 days for uncomplicated bacterial cases, extended to 10-14 days if meningitis is documented 2

Role of Steroids

Steroids have no established role in the treatment of pediatric orchitis:

• Current evidence indicates that steroids are ineffective for conservative treatment of orchitis, including granulomatous orchitis 4
• No guideline recommendations support steroid use for infectious orchitis in infants 2

Critical Management Pitfalls to Avoid

• Do not give empiric antibiotics to all cases - 91% of pediatric epididymo-orchitis patients receive antibiotics despite only 4.1% having bacterial infections 1
• Do not use non-culture diagnostic tests (Gram stains, DNA probes, EIA) for gonococcal diagnosis in children due to false-positive risks and legal implications 2
• Do not assume antibiotics will help viral orchitis - mumps and other viral causes require supportive care only 3
• Do not delay evaluation for disseminated infection if gonococcal orchitis is confirmed - infants require hospitalization and evaluation for sepsis, arthritis, and meningitis 2

Follow-Up Requirements

• Urine cultures should be sent on all pediatric patients with orchitis to guide therapy decisions 1
• Follow-up cultures are necessary to ensure treatment effectiveness when antibiotics are used 2
• If ceftriaxone is used for gonococcal infection, follow-up cultures are unnecessary unless symptoms persist 5
• Evaluate mothers and sexual contacts if gonococcal infection is confirmed, as this raises concerns for sexual abuse requiring mandatory reporting 2