What are the recommended antibiotics for epididimo-orchitis?

Antibiotic Treatment for Epididymo-Orchitis

Age-Based Treatment Algorithm

For sexually active men under 35 years, treat with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days to cover both gonorrhea and chlamydia. 1, 2, 3

For men over 35 years, treat with levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days to cover enteric organisms. 1, 4, 3

Treatment Selection Based on Patient Age and Risk Factors

Men ≤35 Years (Sexually Transmitted Etiology)

• The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, requiring dual coverage 5, 1, 3
• Recommended regimen: Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 5, 1, 2
• Alternative regimen if gonorrhea is excluded by negative Gram stain and low risk: Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 5, 1
• For men who practice insertive anal intercourse, use ceftriaxone PLUS levofloxacin or ofloxacin (not doxycycline alone) to cover enteric organisms 3

Men >35 Years (Enteric Organism Etiology)

• The primary pathogens are enteric Gram-negative bacteria (especially E. coli) associated with urinary tract infections and bladder outlet obstruction 1, 4, 3
• First-line treatment: Levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days 1, 4, 3
• Critical pitfall: Do NOT use doxycycline alone in this age group, as it inadequately covers enteric organisms 4
• Rising fluoroquinolone resistance in E. coli is a growing concern, though fluoroquinolones remain guideline-recommended first-line therapy 6

Essential Diagnostic Workup Before Treatment

• Obtain urethral Gram stain looking for ≥5 polymorphonuclear leukocytes per oil immersion field to confirm urethritis 5, 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis from urethral swab or first-void urine 5, 1
• Urine culture and Gram stain for enteric organisms, especially in men >35 years 5, 4
• Do not delay empiric antibiotic therapy while awaiting culture results 5, 4

Adjunctive Measures (Required for All Patients)

• Bed rest until fever and local inflammation subside 5, 1, 4
• Scrotal elevation using rolled towels or supportive underwear 1, 7
• Analgesics for pain control 1, 7

Critical Follow-Up and Red Flags

• Reevaluate within 3 days if no clinical improvement occurs 1, 7
• Failure to improve within 72 hours requires reconsideration of diagnosis and possible hospitalization 5, 1, 8
• Persistent swelling after completing antibiotics warrants evaluation for testicular cancer, tuberculosis, fungal infection, abscess, or tumor 5, 1

Emergency Exclusion of Testicular Torsion

• Testicular torsion must be ruled out immediately in all cases, especially with sudden severe pain onset, in adolescents, or when no signs of infection are present 1, 7
• Emergency surgical consultation is indicated when torsion cannot be excluded clinically 1

Sexual Partner Management

• Partners should be evaluated and treated if contact occurred within 60 days of symptom onset 1
• Patients must abstain from sexual intercourse until both patient and partners complete therapy and are symptom-free 5, 1

Special Populations

• HIV-positive patients with uncomplicated epididymitis receive the same treatment as HIV-negative patients 1, 7
• Fungal and mycobacterial causes are more common in immunocompromised patients and should be considered if standard therapy fails 5, 1
• Consider hospitalization for severe pain, fever, or concerns about medication compliance 4