Severe Orchitis: Antibiotic Selection
For severe orchitis, initiate empiric therapy with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days, as this combination covers both sexually transmitted pathogens (gonorrhea and chlamydia) and provides adequate tissue penetration for testicular inflammation. 1
Age-Based Treatment Algorithm
Men ≤35 Years (STI-Associated Orchitis)
Primary regimen:
- Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 10 days 1, 2
- This targets Chlamydia trachomatis and Neisseria gonorrhoeae, the most common pathogens in this age group 2
- Ceftriaxone provides sustained bactericidal levels and 98.9% cure rates for gonococcal infections 1
- Doxycycline achieves excellent tissue penetration into the epididymis and testis 1
Alternative for cephalosporin allergy:
- Levofloxacin 500 mg orally once daily for 10 days 1, 2
- Critical caveat: Fluoroquinolones should NOT be used for men who have sex with men (MSM) or those with recent travel to areas with quinolone-resistant gonorrhea (California, Hawaii, Asia, Pacific regions) 1
Men >35 Years (Enteric Organism-Associated)
Primary regimen:
- Levofloxacin 500 mg orally once daily for 10 days 1, 2
- Targets enteric organisms (E. coli, other coliforms) associated with urinary tract abnormalities 3, 2
- Provides excellent penetration into genital tissues 4
Alternative regimen:
- Ofloxacin 300 mg orally twice daily for 10 days 1
Important consideration: Rising fluoroquinolone resistance in E. coli (particularly ciprofloxacin resistance) necessitates considering local resistance patterns 3. If local ciprofloxacin resistance exceeds 10%, alternative agents with adequate tissue penetration should be selected 3
Critical Clinical Pearls
Always Cover Chlamydia in Younger Men
- Even when treating for gonorrhea, chlamydial co-infection occurs frequently at genital sites 1
- The combination regimen prevents treatment failure and reduces complications including infertility and chronic pain 1
Severe Cases Requiring Hospitalization
- For patients unable to tolerate oral medications, with systemic toxicity, or risk of urosepsis, initiate IV therapy 5
- Ceftriaxone 1-2 g IV once daily can be used initially, transitioning to oral therapy once clinically improved 5
- Consider broader coverage with piperacillin-tazobactam for healthcare-associated infections 5
Adjunctive Measures
- Bed rest, scrotal elevation, and analgesics until fever and inflammation subside 1
- These supportive measures are essential components of management 1
Diagnostic Considerations Before Treatment
Obtain these studies to guide therapy:
- Gram stain of urethral exudate (>5 PMNs per oil immersion field indicates urethritis) 1
- NAAT testing for N. gonorrhoeae and C. trachomatis 1, 6
- First-void urine analysis and culture 1
- Syphilis serology and HIV testing 1
Follow-Up and Treatment Failure
Re-evaluate if no improvement within 3 days 1
- Persistent swelling/tenderness after completing therapy requires comprehensive evaluation 1
- Differential includes abscess, testicular infarction, tumor, tuberculosis, or fungal infection 1
- Consider testicular ultrasound with Doppler to assess for complications 7
Sex Partner Management
All sex partners within 60 days of symptom onset require evaluation and treatment 1
- Patients must abstain from sexual intercourse until both they and partners complete therapy and are asymptomatic 1
Common Pitfalls to Avoid
- Do not use fluoroquinolones empirically in MSM due to high rates of quinolone-resistant gonorrhea (23.9% in this population) 1
- Do not use quinolones for infections potentially acquired in California, Hawaii, or internationally without susceptibility testing 1
- Do not delay treatment waiting for culture results—empiric therapy based on age and risk factors is essential 1, 2
- Do not undertreated duration—10 days is required for adequate tissue penetration and eradication 1, 2