What is the best course of treatment for a 9-year-old male with suspected acute orchitis, presenting with penile itching, inflammation, and right testicular pain, who recently completed a course of antibiotics for food poisoning and has been started on Azithromycin (Azithromycin) 250 MG orally daily for 3 days?

Reassess the Diagnosis—This is Likely NOT Orchitis

Stop the azithromycin immediately and treat the actual problem: this 9-year-old has candidal balanitis (yeast infection) from recent antibiotic use, not acute orchitis. The clinical picture does not support bacterial orchitis, and prescribing azithromycin is inappropriate and potentially harmful.

Critical Diagnostic Red Flags

The presentation strongly argues against orchitis:

• Timing and trigger: Symptoms began after completing antibiotics for food poisoning, which is the classic setup for candidal overgrowth 1
• Primary symptoms: Penile itching with white coating at the glans is pathognomonic for candidal balanitis, not bacterial infection 1
• Testicular pain pattern: The testicular discomfort (5/10, tender to touch) began after the penile symptoms and is likely referred pain from scratching and local inflammation, not primary testicular pathology 2
• Absence of infectious orchitis features: No fever, no scrotal swelling/erythema, no dysuria, no urethral discharge—all of which should be present in true bacterial orchitis 1, 2

Why Azithromycin is Wrong Here

Azithromycin 250 mg daily for 3 days is inadequate for any form of bacterial orchitis and addresses the wrong pathogen entirely:

• For sexually transmitted orchitis (chlamydia/gonorrhea), CDC guidelines require ceftriaxone 250 mg IM plus doxycycline 100 mg twice daily for 10 days, not azithromycin monotherapy 1, 3
• For enteric organism orchitis (E. coli), fluoroquinolones like levofloxacin 500 mg daily are required 1, 3
• The 3-day azithromycin course at 250 mg daily provides subtherapeutic dosing even for chlamydial coverage (which requires 1 gram single dose) 4
• Most critically: this child has a fungal infection, not a bacterial one 1

Correct Treatment Approach

Treat the candidal balanitis:

• Topical antifungal cream (clotrimazole 1% or miconazole 2%) applied twice daily to affected areas for 7-10 days 1
• Gentle hygiene with warm water, avoiding soaps that can worsen irritation 1
• Keep area dry; consider brief periods without underwear to reduce moisture 1

Monitor the testicular discomfort:

• If testicular pain persists beyond 48-72 hours of treating the balanitis, or if new symptoms develop (fever, scrotal swelling, severe pain), obtain scrotal ultrasound with Doppler to rule out true orchitis or torsion 1, 2
• The current testicular tenderness should resolve as the primary candidal infection and associated scratching/irritation improve 2

When to Actually Treat for Orchitis

Only consider bacterial orchitis treatment if:

• Scrotal ultrasound confirms orchitis with increased testicular blood flow and enlargement 2
• Fever >38°C develops with systemic symptoms 1, 3
• Urethral discharge or dysuria appears (suggesting STI-related orchitis, though highly unlikely in a 9-year-old without sexual activity) 1
• In prepubertal boys, enteric organisms or viral causes (mumps) are more common than STIs 1, 3

Critical Safety Point

In a 9-year-old with no sexual activity history, prescribing antibiotics for presumed orchitis without proper workup risks missing serious pathology (testicular torsion, tumor) and contributes to antibiotic resistance 1, 2. The mother's observation of "scratching due to yeast infection" is likely correct—trust the clinical picture.