From the Guidelines
The most effective treatment for acute epididymo-orchitis involves administering Ceftriaxone 125 mg IM in a single dose, OR Cefixime 400 mg orally in a single dose, PLUS Azithromycin 1 g orally in a single dose, OR Doxycycline 100 mg orally twice a day for 7 days, as recommended by the 1998 guidelines for treatment of sexually transmitted diseases 1. When considering the treatment of acute epididymo-orchitis, it's crucial to differentiate between sexually transmitted and non-sexually transmitted cases, as the causative organisms and thus the antibiotic regimens differ.
- For sexually transmitted cases, which are common in men under 35, the focus is on covering Neisseria gonorrhoeae and Chlamydia trachomatis.
- For non-sexually transmitted cases, which are more common in older men or following urinary tract instrumentation, the focus shifts to covering enteric bacteria such as Escherichia coli. Given the provided evidence, the recommended regimen from the 1998 guidelines for treatment of sexually transmitted diseases is the most directly relevant, emphasizing the use of cephalosporins like ceftriaxone or cefixime, alongside azithromycin or doxycycline for comprehensive coverage 1. Key considerations in the management of acute epididymo-orchitis include:
- Prompt initiation of antibiotic therapy to prevent complications such as abscess formation or infertility.
- The use of supportive measures including bed rest, scrotal elevation, and analgesics to manage symptoms.
- The importance of treating sexual partners if a sexually transmitted infection is confirmed to prevent reinfection and public health implications. While the provided study is from 1998, its recommendations remain a cornerstone in the approach to treating acute epididymo-orchitis, especially in the context of sexually transmitted infections, highlighting the need for broad-spectrum coverage that includes both gonococcal and chlamydial infections 1.
From the FDA Drug Label
Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days. Acute epididymo-orchitis caused by C. trachomatis: 100 mg, by mouth, twice a day for at least 10 days The antibiotics of choice for acute epididymo-orchitis are doxycycline for C. trachomatis and doxycycline or other antibiotics effective against N. gonorrhoeae, with doxycycline being specified for N. gonorrhoeae in the provided label 2.
- The recommended dose is 100 mg, by mouth, twice a day for at least 10 days.
From the Research
Antibiotics of Choice for Acute Epididymo-Orchitis
The choice of antibiotics for acute epididymo-orchitis depends on the suspected causative pathogens, which vary by age group.
- For men under 35 years old, the most common pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae 3.
- For men over 35 years old, the most common pathogen is E. coli 4, 5, 3.
Recommended Antibiotic Regimens
Based on the suspected pathogens, the following antibiotic regimens are recommended:
- For Chlamydia trachomatis and Neisseria gonorrhoeae, ceftriaxone and doxycycline are recommended 3.
- For E. coli and other coliform bacteria, ofloxacin or levofloxacin may be recommended, but fluoroquinolone resistance is a concern 4, 3.
- In cases where multiple drug resistance is suspected, such as in patients with indwelling urethral catheters, empirical treatment with both a fluoroquinolone and a third-generation cephalosporin may be necessary until antimicrobial susceptibility testing is completed 6.