What is the recommended antibiotic treatment for a patient with orchitis?

Orchitis Antibiotic Treatment

For 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

Age-Stratified Treatment Algorithm

Men Under 35 Years (Sexually Transmitted Etiology)

First-line regimen:

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
• This dual therapy targets both Neisseria gonorrhoeae and Chlamydia trachomatis, the predominant pathogens in this age group 1, 3

Alternative regimen (for cephalosporin/tetracycline allergy):

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1

Men Over 35 Years (Enteric Organism Etiology)

First-line regimen:

• Ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 2
• Enteric bacteria (particularly E. coli) are the primary pathogens in this age group, often associated with bladder outlet obstruction or urethral stricture 3, 4

Important caveat: Rising fluoroquinolone resistance in E. coli isolates may necessitate alternative antimicrobials based on local resistance patterns 4

Critical Diagnostic Steps Before Treatment

Essential testing to guide therapy:

• Gram stain of urethral exudate or intraurethral swab to identify polymorphonuclear leukocytes 1, 5
• Nucleic acid amplification test (NAAT) for N. gonorrhoeae and C. trachomatis 1, 5
• First-void urine analysis and culture if urethral gram stain is negative 1

Emergency exclusion: Immediately rule out testicular torsion by looking for sudden onset severe pain, absent cremasteric reflex, and abnormal testicular lie 1, 6

Treatment Duration and Supportive Care

Antibiotic duration:

• Continue treatment for 10 days for both age groups 1, 7
• The FDA label confirms doxycycline 100 mg orally twice daily for at least 10 days for acute epididymo-orchitis caused by N. gonorrhoeae or C. trachomatis 7

Adjunctive measures:

• Bed rest until fever and inflammation subside 1, 6
• Scrotal elevation using rolled towels or supportive underwear 1, 6
• Analgesics for pain control 1, 6
• Abstain from sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic 1, 5

Common Pitfalls to Avoid

Do not delay treatment while awaiting culture results 1

Do not prescribe single-agent therapy when dual coverage is indicated (i.e., in men under 35 years) 1

Do not conclude the etiology is purely traumatic without obtaining urethral swab or first-void urine for testing 6

Mandatory Reassessment Timeline

Reassess patients who fail to improve within 3 days:

• Consider alternative diagnoses including testicular torsion, tumor, abscess, testicular infarction, or fungal infection 1, 5, 6
• Obtain urgent surgical consultation if testicular torsion is suspected 1
• Consider imaging and tumor marker assessment for persistent symptoms 1

Sexual Partner Management

For sexually transmitted infections:

• Notify and treat all sexual partners within 60 days preceding symptom onset 1, 5
• Provide empiric treatment for both gonorrhea and chlamydia if sexually transmitted infection is suspected 1

Special Populations

HIV-infected or immunocompromised patients:

• Use the same antibiotic regimens as HIV-negative patients 1, 5
• Maintain higher suspicion for atypical organisms such as fungi and mycobacteria 1, 5

Pregnant women:

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