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Case of the Month

November 2017

Dr Marcelle Le Roux (Sefako Makgatho Health Sciences University) & Frans Radebe (NICD/NHLS)

A 20-year old student presented to a dedicated STI clinic complaining of abnormal vaginal discharge and pain during intercourse. She became sexually involved with a new partner about a month ago. She has no family physician. Her symptoms appeared 5-7 days ago. The date of her last known menstrual period was 2 weeks ago.

Question 1: How would you diagnose and screen the patient?

Answer to Q1

In order to perform a proper clinical assessment it is important to take a good sexual history and undertake a thorough ano-genital examination. The history should include questions concerning symptoms, recent sexual history, sexual orientation, type of sexual activity (oral, vaginal, anal sex), the possibility of pregnancy (females), use of contraceptives including condoms, recent antibiotic history, any drug allergies, and recent overseas travel.

Diagnosis
  • Perform a complete abdominal and pelvic examination (including speculum and bimanual examinations). Any patient with lower abdominal pain should receive a complete pelvic examination
  • Take an endocervical swab to test for gonorrhoea, chlamydia, trichomonas and mycoplasma
  • Take rectal and pharyngeal swabs - colonisation can occur without anal penetration
  • Request Nucleic Acid Amplification Tests (NAAT) for all 4 pathogens, and culture for gonorrhoea to allow for antimicrobial susceptibility testing.


Examination confirms vaginal discharge and lower abdominal tenderness.

Question 2 How would you treat the patient?
Answer to Q1

In order to perform a proper clinical assessment it is important to take a good sexual history and undertake a thorough ano-genital examination. The history should include questions concerning symptoms, recent sexual history, sexual orientation, type of sexual activity (oral, vaginal, anal sex), the possibility of pregnancy (females), use of contraceptives including condoms, recent antibiotic history, any drug allergies, and recent overseas travel.

Diagnosis
  • Perform a complete abdominal and pelvic examination (including speculum and bimanual examinations). Any patient with lower abdominal pain should receive a complete pelvic examination
  • Take an endocervical swab to test for gonorrhoea, chlamydia, trichomonas and mycoplasma
  • Take rectal and pharyngeal swabs - colonisation can occur without anal penetration
  • Request Nucleic Acid Amplification Tests (NAAT) for all 4 pathogens, and culture for gonorrhoea to allow for antimicrobial susceptibility testing.
Examination confirms vaginal discharge and lower abdominal tenderness.

Question 2 How would you treat the patient?
Answer to Q2
The three diseases most frequently associated with vaginal discharge are bacterial vaginosis, trichomoniasis and candidiasis. As she is symptomatic (vaginal discharge AND lower abdominal tenderness), treatment will be presumptive and follow national treatment guidelines for lower abdominal pain (LAP).

  • Ceftriaxone IM 250 mg single dose (dissolved in 0.9ml lidocaine 1% without epinephrine [adrenaline]) AND
  • Azithromycin, oral, 1 g as a single dose AND
  • Metronidazole, oral, 400 mg 12 hourly for 7 days

Neisseria gonorrhoeae has developed antibiotic resistance to all drugs previously and currently recommended for empirical monotherapy. Recently, failures to treat pharyngeal gonorrhoea with ceftriaxone (the last option) have emerged in Japan, Australia, Sweden, and Slovenia, and high level resistance was seen in vitro. CDC recommends dual therapy, or using two drugs, to treat gonorrhoea. Empirical dual antibiotic therapy (ceftriaxone 250–1000 mg plus azithromycin 1–2 g) has been introduced in several countries as last resort for untreatable N. gonorrhoeae. Although these treatment regimens appear currently effective it will not entirely prevent resistance emergence and treatment failures with these dual antibiotic regimens will emerge. Accordingly, novel affordable antimicrobials for monotherapy or inclusion in dual treatment regimens are essential.

In vitro activity studies examining collections of geographically, temporally and genetically diverse gonococcal isolates, including multidrug-resistant strains particularly with resistance to ceftriaxone and azithromycin, are important. It is important to include anogenital and pharyngeal isolates, as treatment failures initially emerge at these anatomical sites.

In addition, it will be ideal if in the future treatment at first health care visit can be individually-tailored, i.e. by novel rapid phenotypic resistance tests and/or genetic point of care resistance tests, including detection of gonococci.

In the absence of a gonococcal vaccine, public health control of gonorrhoea is relying on effective, accessible and affordable antibiotic treatment, i.e., combined with appropriate prevention, diagnostics (index cases and traced sexual contacts), and epidemiological surveillance. WHO publications recommend laboratory parameters to verify treatment failures, which ideally require examining pre- and post-treatment isolates for extended-spectrum cephalosporin (ESC) Minimum Inhibitory Concentrations, molecular epidemiological genotype, and genetic resistance determinants. Additionally, a detailed clinical history that excludes reinfection and records the treatment regimen(s) used is mandatory.

NOTE – Doxycycline is no longer part of the regimen and has been substituted with Azithromycin
  • Effective for chlamydial /mycoplasma infections and post-gonococcal urethritis
  • Preferred to doxycycline as higher gonococcal resistance to doxycycline
  • Improved adherence
Question 3. Are there any additional steps that you would take?
Answer to Q3
  • Counsel the patient on prevention.
  • Infection with one STI increases the chance of others being present.
  • HIV transmission and acquisition is enhanced in people with STIs
  • Untreated STIs in women can result in upper genital tract infection which may result in pelvic inflammatory disease, infertility, or ectopic pregnancy.
  • STIs are efficiently transmitted from males to females via vaginal intercourse, rectal intercourse, and fellatio.
  • The patient should abstain from intercourse until therapy is completed and until her and her sex partners no longer have symptoms.
  • All partners should be notified; tested; empirically treated regardless of clinical findings and without waiting for test results.

Outcome of the case
Results of laboratory tests
Urethral and pharyngeal culture showed growth of a Gram-negative diplococcus that was oxidase-positive. Biochemical and fluorescent-antibody conjugate testing confirmed this isolate to be N. gonorrhoeae at both anatomic sites. NAATs positive for Neisseria gonorrhoeae. Ceftriaxone susceptible.

Patient did not return

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