A 21-year-old man comes to the urgent care center due to 3 days of dysuria. The patient also reports a burning sensation at the urethral meatus but has had no fever, urinary urgency, or abdominal or scrotal pain. He has no chronic medical conditions and takes no medications. The patient has had 2 recent female sexual partners and does not use condoms. Vital signs are within normal limits. Physical examination shows mucopurulent penile discharge. No genital ulcers or rash is noted. The scrotum is nontender, and there is no inguinal lymphadenopathy. Rectal examination shows a normal-sized prostate with no tenderness. Urine dipstick is positive for leukocytes but negative for nitrites. Urine microscopy and nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis are sent. Which of the following is the best next step in management of this patient?

Question

A 21-year-old man comes to the urgent care center due to 3 days of dysuria.  The patient also reports a burning sensation at the urethral meatus but has had no fever, urinary urgency, or abdominal or scrotal pain.  He has no chronic medical conditions and takes no medications.  The patient has had 2 recent female sexual partners and does not use condoms.  Vital signs are within normal limits.  Physical examination shows mucopurulent penile discharge.  No genital ulcers or rash is noted.  The scrotum is nontender, and there is no inguinal lymphadenopathy.  Rectal examination shows a normal-sized prostate with no tenderness.  Urine dipstick is positive for leukocytes but negative for nitrites.  Urine microscopy and nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis are sent.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d28a_52f1_bc81_fffb99a49337_MD0003_00 This young man has dysuria and mucopurulent penile discharge, indicating infectious urethritis. Most cases occur in the setting of high-risk sexual activity (eg, unprotected sex) and are caused by sexually transmitted infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium. Manifestations include dysuria, pruritus, burning, and/or urethral meatus discharge, but asymptomatic infection occurs in ~10% of gonococcal and ~50% of nongonococcal infections. The diagnosis of infectious urethritis is made when ≥1 of the following are present: Purulent or mucopurulent penile discharge ≥2 leukocytes per field on urethral swab Gram stain Positive leukocytes on urine dipstick or ≥10 leukocytes/hpf on urinalysis Identification of the underlying organism is generally made with nucleic acid amplification testing (NAAT) of a urethral swab, but Gram stain can rapidly differentiate gonococcal (intracellular gram-negative diplococci) from nongonococcal (no visible organisms) urethritis when available. To reduce sequalae (eg, prostatitis, epididymitis) and risk of transmission, men with infectious urethritis are treated empirically at the time of care while awaiting NAAT results. First-line empiric treatment when N gonorrhoeae and C trachomatis status are unknown is a single dose of intramuscular ceftriaxone plus a 7-day course of oral doxycycline, which provides dual coverage (ceftriaxone plus doxycycline) against potential N gonorrhoeae infection and monotherapy (doxycycline) against potential Chlamydia infection. (Choice A) Although azithromycin is first-line treatment for isolated C trachomatis infections, it is no longer recommended for empiric therapy when gonococcus is (or may be) present due to increasing rates of azithromycin resistance in this organism. Metronidazole is the treatment of choice for infectious urethritis due to Trichomonas vaginalis; however, this organism is not part of initial testing or empiric treatment because it is a less common cause of urethritis in men. (Choice C) Trimethoprim-sulfamethoxazole provides coverage against many coliform organisms (eg, Escherichia coli). Although older men with prostatic hypertrophy are at risk for infectious urethritis with coliform bacteria, these organisms are uncommon in young men and are often associated with positive nitrites on urinalysis. (Choices D and E) Therapy should not be delayed for test results due to high risk of transmission to others and progressive disease. Empiric treatment at the time of care is recommended, with NAAT obtained to confirm the diagnosis and causative organism and to potentially inform management decisions (eg, in case of recurrent or persistent symptoms). Educational objective: Infectious urethritis in young men is usually due to sexually transmitted infection. Nucleic acid amplification testing provides confirmation, but patients with suspected infection should be treated at the time of care. When the organism is unknown, ceftriaxone plus doxycycline is recommended to cover Neisseria gonorrhoeae and Chlamydia trachomatis, the 2 most common organisms. References: Adherence to CDC recommendations for the treatment of uncomplicated gonorrhea - STD Surveillance Network, United States, 2016. (http://www.ncbi.nlm.nih.gov/pubmed/29698384)

A 21-Year-Old Man Comes to the Urgent Care Center Due