What empiric antibiotic(s) should be given to an 11‑year‑old male with suspected epididymo‑orchitis, considering possible sexually transmitted infection?

Empiric Antibiotic Treatment for Suspected Epididymo-Orchitis in an 11-Year-Old

For an 11-year-old male with suspected epididymo-orchitis and possible sexually transmitted infection, treat with ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

Age-Specific Pathogen Considerations

Critical distinction: While sexually transmitted epididymitis is most common in men under 35 years, an 11-year-old represents a special scenario requiring careful evaluation. 1

• If sexual activity or abuse is suspected: The most likely pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, requiring dual therapy as outlined above. 1, 2
• If no sexual activity: Enteric organisms (particularly E. coli) become more likely, even in this age group, especially with any history of urinary tract abnormalities or recent instrumentation. 1

Recommended Empiric Regimen for Sexually Transmitted Etiology

Dual therapy is mandatory because coinfection rates between gonorrhea and chlamydia are substantial, and untreated chlamydia leads to complications including chronic pain and potential infertility. 3, 2

• Ceftriaxone 250 mg IM as a single dose (covers N. gonorrhoeae) 1
• PLUS Doxycycline 100 mg orally twice daily for 10 days (covers C. trachomatis) 1, 4

Doxycycline dosing in children: For children weighing less than 100 pounds, the FDA-approved dose is 2 mg/lb divided into two doses on day 1, followed by 1 mg/lb daily (or divided twice daily) thereafter. 4 However, CDC guidelines for epididymitis specifically recommend 100 mg twice daily for at least 10 days regardless of weight in this clinical scenario. 4

Alternative Regimen for Enteric Organisms

If enteric organisms are more likely (no sexual activity, urinary symptoms, history of urinary abnormalities, or recent instrumentation):

• Ofloxacin 300 mg orally twice daily for 10 days 1
• Note: Fluoroquinolones are generally avoided in children due to concerns about cartilage toxicity, but may be considered when benefits outweigh risks in serious infections. 1

Critical Diagnostic Steps Before Treatment

Obtain these tests immediately, but do not delay empiric therapy: 1

• Gram stain of urethral exudate or intraurethral swab (≥5 PMNs per oil immersion field indicates urethritis) 1
• Urethral culture or NAAT for N. gonorrhoeae and C. trachomatis 1
• First-void urine for leukocytes, culture, and Gram stain 1
• Syphilis serology and HIV counseling/testing 1

Testicular Torsion Must Be Excluded

Testicular torsion is a surgical emergency and is more frequent in adolescents. 1

• Suspect torsion when: sudden onset of severe pain, pain without evidence of urethritis or UTI, or when the cremasteric reflex is absent. 2
• If diagnosis is uncertain: obtain immediate surgical consultation because testicular viability is time-dependent. 1
• Epididymitis presentation: gradual onset of unilateral testicular pain and tenderness, palpable epididymal swelling, intact cremasteric reflex, and often accompanying urethritis symptoms. 2

Adjunctive Measures

• Bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1
• Sexual abstinence for 7 days after completing therapy and until symptoms resolve. 3

Partner Management and Abuse Considerations

In an 11-year-old, the possibility of sexual abuse must be considered and reported according to local mandatory reporting laws. 1

• All sexual partners within 60 days must be evaluated and treated empirically for both gonorrhea and chlamydia, regardless of symptoms. 1, 3
• Social services and law enforcement should be involved if abuse is suspected. 1

Follow-Up Requirements

• Re-evaluate within 72 hours if no clinical improvement. 1
• Failure to improve requires reassessment of diagnosis (consider abscess, tumor, testicular cancer, or fungal/tuberculous infection) and therapy. 1
• Microbiologic re-examination 7-10 days after completing therapy is recommended for C. trachomatis. 1
• Retesting at 3 months for gonorrhea and chlamydia due to high reinfection rates. 3

Common Pitfalls to Avoid

• Never use ceftriaxone alone without chlamydia coverage—this leaves a substantial proportion of infections untreated. 3
• Never use quinolones for gonorrhea due to widespread resistance. 3
• Do not delay treatment waiting for culture results—empiric therapy must be initiated immediately. 1, 3
• Do not overlook testicular torsion in the differential diagnosis, especially in adolescents with acute severe pain. 1, 2