Non-Testicular Torsion Acute Scrotum - Is Use of Prophylactic Antibiotics in Patients with a Normal Urine Analysis Justified?
Thomas Kozar, BA1, Amanda Fang, BS1, Kelsey Hall, BS2, Pankaj P. Dangle, MD, MCh3.
1University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA, 2Auburn University Harrison School of Pharmacy, Birmingham, AL, USA, 3Children's of Alabama, Birmingham, AL, USA.
Background: Differential diagnosis for non-testicular torsion (NTT) acute scrotum includes epididymitis, epididymo-orchitis (EO), orchitis, and torsion of the appendix/epididymis testes. The current management surrounding uncomplicated pediatric NTT acute scrotum has been variable regarding the necessity of antibiotics. Our hypothesis is that empirical antibiotic treatment for NTT acute scrotum is unnecessary in the setting of a normal urine analysis (UA).
Methods: After IRB approval, retrospective chart review revealed 314 pediatric patients with clinically diagnosed NTT acute scrotum with negative UA between 2004-2019. Exclusion criteria included previous urological history and immunocompromised state. Groups were divided into with and without use of antibiotics. Data was analyzed using SPSS where p<0.05 was considered significant. The independent t-test was used to compare numerical variables while the chi-squared test was used to compare categorical variables.
Results: Of the 314 patients identified, 141 (44.9%) received empiric antibiotics despite negative UA. Clinical findings such as scrotal erythema (43.6 vs 39.2%, p=0.44), tenderness to palpation (93.6 vs 96.5%, p=0.24), swelling (62.4 vs 53.2%, p=0.10) and the presence of reactive hydrocele(s) (6.4 vs 7.6%, p=0.68) were not significant. No significant difference seen in race (p=0.54), circumcision status (85.6 vs 87.7%, p=0.63), and average age of presentation (9.9 vs 10.2, p=0.57).
Patients clinically diagnosed with EO were more likely to be prescribed antibiotics (48.2 vs 30.6%, p=0.02). Trimethoprim-sulfamethoxazole accounted for 83% of the antibiotics that were prescribed in our study.
There was no significant difference in symptom resolution between patients prescribed antibiotics compared to those without (5.1 days vs 4.6 days, p=0.71). Additionally, no patient in either group returned with complications such as worsening symptoms or urinary tract infection till the scheduled follow up visit.
Conclusion: Based on our analysis, antibiotics in NTT acute scrotum appears to have no benefit in symptom resolution or complication reduction in patients without any predisposing urological risk factors and negative UA at presentation. Given the risk and rise of antibiotic resistance we need to be careful and cognizant to select treatments based on available evidence.
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