A tale of resistant Escherichia coli epididymo-orchitis in an HIV-positive individual

Case

A 41-year old male who has sex with men (MSM) who was diagnosed human immunodeficiency virus (HIV) positive in 2006, was on Atripla with a CD4 count of 452 and an undetectable viral load. He had Kaposi’s sarcoma in 2006. He had a history of recurrent urinary tract infections (UTIs) and epididymo-orchitis. His renal and testicular ultrasound scans, as well as urinary flow studies, were normal.

In March 2013, he presented with fever, dysuria and left testicular pain and swelling. Initial treatment with 7 days of ciprofloxacin by the General Practitioner (GP) for UTI was followed by a urological admission and inpatient ofloxacin treatment, in accord with hospital and British Society for Sexual Health and HIV (BASHH) guidelines. He continued to have persistent fever and painful testicular swelling. A sexually transmitted infection screen was negative for chlamydia and gonorrhoea. A mid-stream urine culture grew Escherichia coli (E. coli) that was resistant to the antibiotics amoxicillin and trimethoprim. It was presumed, based on the resistance profile, that this organism also had resistance to quinolones. Nitrofurantoin 100 mg four times a day for 7 days led to rapid resolution of symptoms. He has been asymptomatic ever since.

Written informed consent was obtained from the patient for his anonymised information to be published in this article. Our institution does not require ethical approval for reporting individual cases, nor case series.

Discussion

Epididymo-orchitis in men > 35 years of age is more frequently associated with enteric, rather than sexually transmitted, organisms. BASHH and The International Union against Sexually Transmitted Infections (IUSTI) guidelines provide limited antibiotic protocols, based on the age of the patient and whether the cause is an enteric or sexually transmitted pathogen.^1,2 We report a case in the context of HIV, where the guidelines failed to provide a successful treatment. The local prevalence of E. coli resistance to amoxicillin has remained at 40–50% over the last 6 years, with trimethoprim resistance at 30% and quinolone resistance at < 10%, according to figures observed by our hospital’s Microbiology Department. ³ We are increasingly observing that HIV-positive or MSM men > 35 years of age with resistant E. coli urinary tract infections are requiring alternative treatment regimens for the management of epididymo-orchitis. Their HIV is well controlled on antiretroviral therapy, with good CD4 counts that are > 350 and undetectable viral loads. The community, hospital, BASHH and IUSTI guidelines do not suggest alternatives, when there is treatment failure. We did not find any reports of this type of treatment failure in a Medline search. Ineffective antibiotic therapy in this patient led to a prolonged inpatient hospital stay, thereby increasing the financial demand on the National Health Service (NHS). This case highlights the need to consider E. coli resistance when treating epididymo-orchitis in older men who have sex with men, despite their HIV status. This patient’s infection proved microbiologically and clinically sensitive to nitrofurantoin.