What is the recommended treatment for a patient with pus in semen analysis, potentially indicating a bacterial infection, and possibly with a history of sexually transmitted infections (STIs)?

Treatment for Pus in Semen Analysis

Treat empirically with doxycycline 100 mg orally twice daily for 7 days as first-line therapy, or azithromycin 1 g orally as a single dose if compliance is a concern, to cover the most common causative organisms (Chlamydia trachomatis, Ureaplasma, and Mycoplasma genitalium). 1, 2

Initial Diagnostic Approach

Pus in semen (pyospermia or leukocytospermia) indicates inflammation or infection of the male genital tract and requires both diagnostic testing and empiric treatment while awaiting results. 3

Key diagnostic steps include:

• Obtain urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis - these are the most sensitive tests available and should guide definitive therapy 1
• Perform Gram stain of urethral exudate or intraurethral swab - looking for ≥5 polymorphonuclear leukocytes per oil immersion field to confirm urethritis 1
• Obtain syphilis serology and offer HIV testing - essential for all patients with suspected STI 1
• Consider semen culture for aerobic and anaerobic bacteria - particularly if standard STI testing is negative, as anaerobic pathogens are found in ~71% of ejaculates and can be pathogenic 3

First-Line Treatment Regimens

Recommended options (choose one):

• Doxycycline 100 mg orally twice daily for 7 days - highly effective for chlamydial and Mycoplasma genitalium infections 1, 2
• Azithromycin 1 g orally as a single dose - preferred when compliance is uncertain, with directly observed therapy recommended 1, 2

The choice between these depends primarily on patient reliability. Single-dose azithromycin ensures completion but doxycycline has a longer track record and lower cost. 1

Alternative Regimens

If doxycycline or azithromycin cannot be used:

• Levofloxacin 500 mg orally once daily for 7 days 1, 2
• Ofloxacin 300 mg orally twice daily for 7 days 1, 2
• Erythromycin base 500 mg orally four times daily for 7 days 1, 2
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 2

Important caveat: Avoid quinolones (levofloxacin, ofloxacin) if gonorrhea is suspected, as resistance rates exceed 20% in many populations. 4

When to Add Gonococcal Coverage

If gonorrhea is suspected or confirmed, add:

• Ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 5

This dual therapy is essential because coinfection with C. trachomatis occurs frequently in patients with gonococcal infection. 1

Special Considerations for Epididymitis

If the patient has unilateral testicular pain, tenderness, or palpable epididymal swelling suggesting epididymitis:

For sexually transmitted pathogens (age <35 years):

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 5

For enteric organisms (age >35 years) or cephalosporin allergy:

• Ofloxacin 300 mg orally twice daily for 10 days 1, 5
• Levofloxacin 500 mg orally once daily for 10 days 5

Adjunctive measures: Bed rest, scrotal elevation, and analgesics until fever and inflammation subside. 1, 5

Critical Management Points

Sexual abstinence is mandatory:

• Patients must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen AND resolution of symptoms 1, 2, 5
• Condoms do not provide adequate protection during active infection treatment, as failure rates are significant even in experienced users 6

Partner management is essential:

• All sexual partners within 60 days preceding symptom onset (or diagnosis if asymptomatic) require evaluation and empiric treatment 1, 2, 5
• Partners should receive the same treatment regimen as the index patient 1, 2
• This prevents reinfection, which is the most common cause of treatment "failure" 1

Follow-Up Strategy

Reassessment at 3 days:

• If no improvement within 3 days, reevaluate both diagnosis and therapy 1, 5
• Consider resistant organisms, non-compliance, reinfection from untreated partner, or alternative diagnoses 1

Test of cure:

• Not routinely needed if symptoms resolve with recommended regimens 1, 4
• Consider retesting 3 weeks after completion if erythromycin or alternative agents were used 1
• Mandatory if symptoms persist or recur 2

Common Pitfalls to Avoid

Do not:

• Delay treatment waiting for culture results - empiric therapy should begin immediately 1
• Use quinolones as first-line for suspected gonorrhea due to widespread resistance 1, 4
• Assume treatment failure is due to resistant organisms without first ruling out reinfection from untreated partners 1
• Overlook the need for HIV and syphilis testing in all patients with suspected STI 1

Do:

• Dispense medications on-site and directly observe the first dose when possible 1
• Emphasize that asymptomatic partners are often the source of reinfection 1
• Consider Mycoplasma genitalium in persistent or recurrent cases, which responds better to azithromycin than doxycycline 1, 2

Special Populations

HIV-infected patients:

• Treat with the same regimens as HIV-negative patients 1, 2, 5
• However, fungi and mycobacteria are more likely in immunosuppressed patients if standard therapy fails 1, 5

Pregnant patients:

• Avoid doxycycline and quinolones 1
• Use azithromycin or erythromycin as alternatives 1, 2