A 23-year-old man comes to the office due to several days of dysuria. He has had no fever or hematuria. The patient has no other medical conditions, takes no medications, and has no known allergies. Temperature is 37.1 C (98.8 F). On genitourinary examination, mucopurulent discharge is noted at the urethral meatus. Microscopy of the discharge shows numerous neutrophils, some of which contain intracellular gram-negative diplococci. A single intramuscular injection of ceftriaxone is administered. Which of the following additional medications is recommended at this time?

Question

A 23-year-old man comes to the office due to several days of dysuria.  He has had no fever or hematuria.  The patient has no other medical conditions, takes no medications, and has no known allergies.  Temperature is 37.1 C (98.8 F).  On genitourinary examination, mucopurulent discharge is noted at the urethral meatus.  Microscopy of the discharge shows numerous neutrophils, some of which contain intracellular gram-negative diplococci.  A single intramuscular injection of ceftriaxone is administered.  Which of the following additional medications is recommended at this time?

Quizplus · Accepted Answer

11ec160b_3bff_e4d8_9249_4302d02bbd37_MD0001_00 This young man with dysuria and penile discharge likely has infectious urethritis due to sexually transmitted infection. Most cases are caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium; simultaneous infection with multiple pathogens is common. Nucleic acid amplification testing (NAAT) of urethral, vaginal, or anal swabs is used to identify the causative organism. When available, light microscopy with Gram stain is performed to rapidly diagnose N gonorrhoeae infection while awaiting NAAT results. Gonococcal urethritis is diagnosed when there are leukocytes with intracellular gram-negative diplococci; nongonococcal urethritis is diagnosed when there are no organisms present (because C trachomatis does not have significant peptidoglycan in the cell wall, it cannot be identified on Gram stain). Treatment is as follows: (Choice B) Fluconazole is a triazole-class antifungal agent used to treat candidiasis, cryptococcosis, histoplasmosis, blastomycosis, and coccidioidomycosis. Fungal urethritis is uncommon in otherwise healthy men. (Choice C) Metronidazole treats anaerobic bacteria and protozoa. It has no activity against N gonorrhoeae or C trachomatis but can be used for urethritis caused by Trichomonas vaginalis. Because T vaginalis is a less common cause of infectious urethritis in men, empiric coverage against T vaginalis is not recommended. (Choice E) Penicillin G benzathine is used to treat syphilis infection, which typically presents with a chancre (primary syphilis) or diffuse rash and lymphadenopathy (secondary syphilis). Treatment for syphilis is not indicated without these characteristic symptoms or a positive syphilis test result. (Choice F) Trimethoprim-sulfamethoxazole is used to treat cystitis or proctitis due to coliform bacilli (eg, Escherichia coli). These organisms can cause urethritis in older men in the setting of prostatic obstruction of the urethra. However, infectious urethritis in young men is almost always caused by sexually transmitted infection, not coliform organisms. Educational objective: Urethritis in young men is usually due to sexually transmitted infection. Treatment for gonococcal urethritis with uncertain or positive Chlamydia coinfection status is ceftriaxone plus doxycycline. Treatment for gonococcal urethritis with negative Chlamydia is ceftriaxone alone. Patients with no gonorrhea who have Chlamydia are treated with azithromycin or doxycycline monotherapy.

A 23-Year-Old Man Comes to the Office Due to Several