A 27-year-old woman comes to the emergency department due to several days of aching pain in her right ankle, left wrist, and hand joints. She has also had subjective fever and malaise. The patient took acetaminophen and ibuprofen, which provided some pain relief. She takes no other medications and has no chronic medical problems. The patient smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine most days. She smokes marijuana occasionally but does not use intravenous drugs. She has been sexually active with 2 partners over the last 6 months and uses condoms inconsistently. The patient works in a retail shop in Massachusetts and has not traveled recently. She has no known allergies. Temperature is 38.1 C (100.6 F), blood pressure is 122/65 mm Hg, pulse is 95/min, and respirations are 16/min. The left hand joints are mildly swollen, and passive extension of the fingers elicits pain. There is tenderness of the left wrist and right ankle with no joint effusion. Skin examination reveals scattered pustules over the patient's distal extremities. The remainder of the physical examination shows no abnormalities. The diagnosis is established, and the patient is appropriately treated. A week later, she comes to the clinic with her partner so that he can be evaluated. He has had no dysuria, urethral discharge, fever, genital ulcers, or rash. They have not had sexual contact since her hospitalization and treatment. Her partner has no known drug allergies. Nucleic acid amplification testing of his urine is positive for Neisseria gonorrhoeae and negative for Chlamydia trachomatis. Which of the following is the most appropriate management strategy for the partner at this time?

Question

A 27-year-old woman comes to the emergency department due to several days of aching pain in her right ankle, left wrist, and hand joints.  She has also had subjective fever and malaise.  The patient took acetaminophen and ibuprofen, which provided some pain relief.  She takes no other medications and has no chronic medical problems.  The patient smokes a pack of cigarettes daily and drinks 1 or 2 glasses of wine most days.  She smokes marijuana occasionally but does not use intravenous drugs.  She has been sexually active with 2 partners over the last 6 months and uses condoms inconsistently.  The patient works in a retail shop in Massachusetts and has not traveled recently.  She has no known allergies.  Temperature is 38.1 C (100.6 F), blood pressure is 122/65 mm Hg, pulse is 95/min, and respirations are 16/min.  The left hand joints are mildly swollen, and passive extension of the fingers elicits pain.  There is tenderness of the left wrist and right ankle with no joint effusion.  Skin examination reveals scattered pustules over the patient's distal extremities.  The remainder of the physical examination shows no abnormalities. The diagnosis is established, and the patient is appropriately treated.  A week later, she comes to the clinic with her partner so that he can be evaluated.  He has had no dysuria, urethral discharge, fever, genital ulcers, or rash.  They have not had sexual contact since her hospitalization and treatment.  Her partner has no known drug allergies.  Nucleic acid amplification testing of his urine is positive for Neisseria gonorrhoeae and negative for Chlamydia trachomatis.  Which of the following is the most appropriate management strategy for the partner at this time?

Quizplus · Accepted Answer

Explanation: Recent sexual partners of individuals diagnosed with Neisseria gonorrhoeae require evaluation and testing regardless of the presence or absence of symptoms because gonococcal urogenital infection can be asymptomatic. Those with uncomplicated urogenital gonococcal infections who have negative Chlamydia testing (eg, nucleic acid amplification testing positive for N gonorrhoeae and negative for Chlamydia trachomatis, as in this patient) are treated with a single dose of intramuscular ceftriaxone, which provides high cure rates. Although dual therapy with ceftriaxone plus azithromycin was previously recommended for urogenital gonorrhea, guidelines have changed due to the increasing rates of azithromycin resistance (Choice A). In contrast, patients with urogenital gonococcus who have positive or uncertain Chlamydia status should be treated with a single dose of intramuscular ceftriaxone plus oral doxycycline to provide dual coverage against N gonorrhoeae and empiric coverage against potential C trachomatis coinfection, which occurs in up to 35% of infected patients. Because Chlamydia does not have significant peptidoglycan in the cell wall, beta-lactam agents have no efficacy against this organism; therefore, adequate empiric coverage requires a tetracycline (in a setting of concurrent gonorrhea) or a macrolide (in the absence of gonorrhea). (Choice C) Culture and sensitivity testing are rarely performed and usually reserved for when initial therapy fails and the patient is thought to have resistant N gonorrhoeae. Because ceftriaxone provides excellent coverage against N gonorrhoeae, treatment failure is rare. (Choice D) Doxycycline monotherapy is considered first-line for nongonococcal urethritis because it has excellent efficacy against C trachomatis. Doxycycline should not be used alone against N gonorrhoeae. (Choice E) Trimethoprim-sulfamethoxazole is a first-line therapy for cystitis but does not adequately treat gonococcus. It is sometimes used in men with infectious urethritis due to coliform organisms; this is seen primarily in men who have penetrative anal sex or older men with prostatic hypertrophy. Educational objective: Uncomplicated urogenital Neisseria gonorrhoeae infection with negative Chlamydia testing should be treated with ceftriaxone monotherapy. Those with gonorrhea who have positive or uncertain Chlamydia status require dual therapy with ceftriaxone plus doxycycline to ensure adequate coverage against potential Chlamydia coinfection.

A 27-Year-Old Woman Comes to the Emergency Department Due to Several