Epididymo-orchitisBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1543 (Published 13 April 2011) Cite this as: BMJ 2011;342:d1543
All rapid responses
In response to the 10 minute consultation article on Epididymo-orchitis by Stewart A et al on 23 April 2011 (BMJ 2011;342:D1543
doi:10.1136/bmj.d1543) we would like to advise of the very recent changes
in the British Association of Sexual Health and HIV (BASHH) guidelines on
the management of Neisseria gonorrhoeae infections (1). Following
analysis of surveillance data from the UK Gonococcal Resistance to
Antimicrobials Programme (GRASP), decreasing sensitivity of this organism
to Cephalosporins has been demonstrated (2). The BASHH Clinical
Effectiveness Group draft guidelines, which were closed for consultation
in March 2011, advise that first-line treatment should now be ceftriaxone
500 mg IM. Second-line treatment, cefixime 400 mg oral, is only considered
if IM injection is contra-indicated or declined by the patient. To note
the European Urology guidelines, as first line treatment for Gonococcal
urethritis, advise a higher dose of ceftriaxone than the UK guidelines, at
1g IM stat (3).
With regards to ciprofloxacin use as an alternative to ceftriaxone,
as suggested in this article, the WHO recommends that the chosen
antimicrobial regimen for Gonorrhoea (GC) should eliminate infection in at
least 95% of isolates from the local community. GRASP data showed that
ciprofloxacin resistance increased from 28% to 35% between 2008 and 2009
with up to 54.0% of gonococcal isolates in men-who-have-sex-with-men being
resistant to this antimicrobial (4). Ciprofloxacin is no longer
recommended as treatment for GC, by either the BASHH or European Urology
guidelines, unless the isolate is known to be sensitive to this
antimicrobial, following culture, or where the regional prevalence of
resistance is known to be less than 5%.
Because of concerning trends in antibiotic resistance, test of cure
is recommended in patients in whom GC has been identified. In addition,
all patients, with suspected or confirmed GC, should be treated,
concurrently, with antibiotics to cover for Chlamydia Trachomatis (CT),
regardless of the CT result. This is because of the high risk of co-
infection of CT, which is seen in up to 20% of men and 40% of women with
Therefore, in the case of suspected epididymo-orchitis, most probably
caused by a sexually transmitted pathogen, the recommended first line
treatment in the UK would be ceftriaxone 500mg IM plus doxycycline 100mg
by mouth twice daily for 10-14 days, once tests have been carried out to
try and identify the cause. Treatment should then be initiated to cover
likely pathogens, whilst awaiting the laboratory test results.
With regards to Gonorrhoea diagnostics, the BASHH UK National
Screening and Testing Guidelines (2006) advise that in a symptomatic male
patient, attending a Genitourinary medicine clinic, urethral gram stain
microscopy, for diagnosis of non-gonococcal urethritis and presumptive
diagnosis of GC, followed by laboratory tests would be the gold standard.
In patients being seen outside of the GUM clinic, laboratory tests are
advised prior to the initiation of antimicrobial therapy. These laboratory
tests are either in the form of a urethral swab sent in transport medium
(Amies or Stuarts) to the laboratory, where the sample would then be
plated onto appropriate media, or Nucleic Acid Amplification tests (NAAT)
on first void urine, which can be tested for both CT and GC. We would
recommend that, if a NAAT is positive for GC, the patient should be
recalled for repeat testing using GC culture, where antibiotic
sensitivities can be identified to ensure that correct treatment is given.
In addition, we would advise that a urinalysis and M,C+S is carried out on
a mid-stream urine sample only, to exclude a urinary tract infection as
the cause of the epididymo-orchitis.
In the case of either a positive GC culture or GC/CT NAAT test we
would strongly recommend referral to a GUM clinic for a full STI screen,
treatment, follow-up for test-of-cure and to arrange partner notification
to ensure that as many sexual contacts are treated to prevent re-infection
and onward transmission.
1. FitzGerald M on behalf of the British Association of Sexual Health
and HIV Clinical Effectiveness Group. Gonorrhoea Treatment - Suggested
Changes Feb 2011. Available at www.bashh.org/documents/3256
2. Chisholm S, Mouton J, Lewis D, Nichols T, Ison C, Livermore D.
Cephalosporin MIC creep among gonococci: time for a pharmacodynamic
rethink? Journal of Antimicrobial Chemotherapy 2010; 65: 2141 - 2148
3. Grabe M, Bjerklund-Johansen TE, Botto H, Wullt B, ?ek M, Naber KG,
Pickard RS, Tenke P, Wagenlehner F. Guidelines on Urological Infections.
European Association of Urology 2011. Available at
4. Gonococcal Resistance to Antimicrobials Surveillance Programme in
England and Wales (GRASP): report of 2009 Health Protection Report Vol 4
No. 34 - 27 August 2010. Available at
Competing interests: No competing interests