What is the recommended antibiotic regimen for the management of orchitis?

Orchitis Antibiotic Management

Primary Recommendation

For orchitis in sexually active men under 35 years, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonococcal and chlamydial infection. 1, 2, 3

---

Age-Based Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Pathogens)

First-Line Regimen:

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1, 2, 3
• This dual therapy targets Neisseria gonorrhoeae and Chlamydia trachomatis, the predominant pathogens in this age group 4
• Doxycycline provides sustained coverage for chlamydial coinfection, which occurs in approximately 50% of gonococcal infections 5

Alternative for Cephalosporin/Tetracycline Allergy:

• Ofloxacin 300 mg orally twice daily for 10 days 1, 2
• OR Levofloxacin 500 mg orally once daily for 10 days 2
• Note: Quinolone resistance is increasing, particularly in infections acquired in Asia or Pacific regions 2

Men Over 35 Years (Enteric Organisms)

First-Line Regimen:

• Ofloxacin 300 mg orally twice daily for 10 days 1, 2
• OR Levofloxacin 500 mg orally once daily for 10 days 2
• Enteric organisms (E. coli, Enterobacteriaceae) predominate in this age group, often associated with bladder outlet obstruction or urinary tract abnormalities 4, 6
• Fluoroquinolones provide superior coverage for coliform bacteria compared to cephalosporins 4

Important Caveat:

• Rising ciprofloxacin resistance in E. coli isolates (particularly in Europe and USA) necessitates consideration of local resistance patterns 6
• If fluoroquinolone resistance is suspected, consider alternative agents with adequate testicular tissue penetration 6

---

Diagnostic Workup Before Treatment

Essential Testing:

• Gram stain of urethral exudate or intraurethral swab (≥5 PMNs per oil immersion field indicates urethritis) 1
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis on urethral swab or first-void urine 1
• First-void urine analysis and culture if urethral Gram stain is negative 1
• Syphilis serology and HIV testing 1

Critical Differential:

• Testicular torsion must be excluded immediately - look for sudden onset, severe pain, absent cremasteric reflex, and abnormal testicular lie 1
• Torsion is more common in adolescents and occurs more frequently when inflammation/infection signs are absent 1
• If diagnosis is uncertain, obtain urgent surgical consultation as testicular viability is time-dependent 1

---

Adjunctive Measures

Supportive Care:

• Bed rest until fever and inflammation subside 1, 2
• Scrotal elevation to reduce pain and swelling 1, 2
• Analgesics for pain control 1, 2

Sexual Activity:

• Abstain from sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 1, 2

---

Follow-Up and Treatment Failure

Reassessment Timeline:

• Failure to improve within 3 days requires immediate reevaluation of diagnosis and therapy 1, 2
• Consider alternative diagnoses: testicular tumor, abscess, infarction, testicular cancer, tuberculous or fungal orchitis 1

Persistent Symptoms After Treatment:

• Comprehensive evaluation including imaging and tumor marker assessment 1
• In immunocompromised patients, maintain higher suspicion for atypical organisms (fungi, mycobacteria) 1, 2, 7

---

Sexual Partner Management

Partner Notification:

• All sexual partners within 60 days preceding symptom onset should be evaluated and treated 1, 2
• Partners should receive empiric treatment for both gonorrhea and chlamydia if sexually transmitted infection is suspected 1, 2
• Partners must also abstain from sexual activity until treatment is completed and symptoms resolve 1, 2

---

Special Populations

HIV-Infected Patients:

• Use the same antibiotic regimens as HIV-negative patients 1, 2, 7
• However, fungi and mycobacteria are more likely causative organisms in immunosuppressed states 1, 2, 7
• If standard therapy fails, pursue comprehensive workup for opportunistic pathogens 2, 7

Pregnancy Considerations:

• Avoid quinolones and tetracyclines in pregnant women 1
• Use cephalosporin-based regimens only 1

---

Common Pitfalls

Do Not:

• Use tetracyclines as sole therapy for gonococcal infection due to resistance 5
• Delay treatment while awaiting culture results - empiric therapy is indicated immediately 1
• Prescribe single-agent therapy when dual coverage is indicated (under 35 years) 1, 2
• Ignore geographic quinolone resistance patterns when prescribing fluoroquinolones 2
• Assume orchitis in patients with sudden, severe pain without ruling out torsion first 1