A 19-year-old man comes to the student health center due to 2 days of burning pain during urination. He has also had itching of the urethral meatus but no urinary discharge, fever, chills, or rash. The patient has no chronic medical conditions and takes no medications. He had unprotected sexual intercourse with a new female partner a week ago. The patient has smoked a pack of cigarettes daily since age 14. He drinks alcohol on weekends and does not use illicit drugs. Vital signs are within normal limits. There is scant, watery urethral discharge at the urethral meatus. There are no genital ulcers, rashes, erythema, or inguinal lymphadenopathy. Urethral swab is performed, and Gram stain of the urethral fluid reveals many neutrophils but no organisms. Nucleic acid amplification tests of the urine are sent for Chlamydia trachomatis and Neisseria gonorrhoeae.
This patient's symptoms are most likely to respond to which of the following?

Question

A 19-year-old man comes to the student health center due to 2 days of burning pain during urination.  He has also had itching of the urethral meatus but no urinary discharge, fever, chills, or rash.  The patient has no chronic medical conditions and takes no medications.  He had unprotected sexual intercourse with a new female partner a week ago.  The patient has smoked a pack of cigarettes daily since age 14.  He drinks alcohol on weekends and does not use illicit drugs.  Vital signs are within normal limits.  There is scant, watery urethral discharge at the urethral meatus.  There are no genital ulcers, rashes, erythema, or inguinal lymphadenopathy.  Urethral swab is performed, and Gram stain of the urethral fluid reveals many neutrophils but no organisms.  Nucleic acid amplification tests of the urine are sent for Chlamydia trachomatis and Neisseria gonorrhoeae.
This patient's symptoms are most likely to respond to which of the following?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf8c_d1c9_8f63_0b7ea55a9c2f_MD0005_00 This young patient had a new, unprotected sexual partner and subsequently developed dysuria and watery urethral discharge, indicating infectious urethritis. Most cases are due to sexually transmitted infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium. Gonorrhea tends to cause profuse, thick discharge, while nongonococcal infections tend to cause scant, watery discharge; however, the underlying organism cannot be diagnosed by symptoms alone. Nucleic acid amplification testing (NAAT) of urethral, vaginal, or anal samples provides definitive diagnosis, but Gram stain can quickly identify the presence of N gonorrhoeae. Gonococcal urethritis is diagnosed when Gram stain shows leukocytes with intracellular gram-negative diplococci. In contrast, nongonococcal urethritis (NGU) is marked by leukocytes with no visible organisms because C trachomatis and M genitalium do not have significant peptidoglycan in their cell wall. Therefore, patients with symptoms of infectious urethritis who have negative Gram stain for N gonorrhoeae (ie, no visible organisms) and are awaiting NAAT results should receive empiric treatment for NGU with azithromycin or doxycycline. Empiric azithromycin adequately treats most cases of C trachomatis, but treatment failure can occur due to antibiotic resistance or to infection with an alternate organism (eg, M genitalium, Trichomonas vaginalis). (Choice B) Gonococcal urethritis is treated empirically with ceftriaxone monotherapy. However, patients with gonorrhea and uncertain or positive C trachomatis testing should also receive empiric doxycycline to treat potential coinfection. This patient with an aseptic Gram stain has nongonococcal, not gonococcal, urethritis and should be treated with azithromycin or doxycycline monotherapy. (Choice C) T vaginalis can cause NGU and is treated with metronidazole. However, metronidazole is not used for empiric treatment of infectious urethritis in men because T vaginalis is much less common than other causes. (Choice D) Coliform organisms (eg, Escherichia coli) can cause infectious urethritis in older men with enlarged prostates. These individuals are often treated with fluoroquinolones (eg, ofloxacin). Young, sexually active men with infectious urethritis usually have sexually transmitted infection, not infection with coliform organism. (Choice E) Valacyclovir treats herpes simplex virus infection, which typically causes painful genital vesicles/ulcerations. Educational objective: Infectious urethritis in young male patients is typically due to sexually transmitted infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium. Diagnosis is made with nucleic acid amplification testing, but urethral fluid Gram stain can quickly differentiate gonococcal (intracellular diplococci) from nongonococcal (aseptic) urethritis. Nongonococcal urethritis is treated empirically with azithromycin or doxycycline.

A 19-Year-Old Man Comes to the Student Health Center Due