Question

Patient Profile

Emilio, a 20-year-old Hispanic male college student, comes to the student health center with pain on urination.

Subjective Data

• Describes pain as, “Just like it felt when I had the clap last year”
• Provides a history of sexual activity since age 15, reports lifetime sexual partners as six women and two men
• Denies injected drug use, tobacco use, or corticosteroid therapy
• Uses alcohol (mainly beer) at weekend parties and has smoked marijuana, but not recently
• Recent sexual activity has been on weekends during or after beer parties

Objective Data

Physical Examination

• 5 feet 11 inches tall, 168 pounds, temp4° F (38° C), purulent urethral discharge noted

Laboratory Studies

• Urine test for Neisseria gonorrhoeae is positive

Collaborative Care

• IM injection with 250 mg ceftriaxone (Rocephin)
• Doxycycline 100 mg PO bid for 7 days

1. What medications would you expect to be ordered and why assuming there is a positive HIV test result?

Answer 1

1.TREATMENT FOR NEISSERIA GONORRHOEA

• N.gonorrhoea has ability to develop resistance to antimicrobials and this resistance can evolve and spread very rapidly.
• Dual therapy which is first line treatment : CEPHALOSPORINS( inj CEFTRIAXONE) 250 mg IM single dose plus tab AZITHROMYCIN 1g single dose.
• Sexual partner should also be treated with the same medication.
• To avoid reinfection sexual partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed the treatment.
• Azithromycin used over doxycycline because of its convenience ,compliance and advantage of single dose and higher prevalence of gonococcal resistance to tetracyclines.
• N.gonorrhoea developed resistance to tab cefixime also so it is not used as first line treatment.Also resistant to pencillins and flouroquinolones.

There is assumption for positive HIV test because:

• Gonococcal infection can facilitate HIV transmission.
• Gonococcal infections induces the epithelial cells to produce cytokines,chemokines and defensins to modulate HIV infection and infectivity.
• Also induces production of cytokines and chemokines in monocytes and modulates T cell activation.
• Modulates HIV specific immune response in HIV exposed sex workers.
• Proteoglycan and gonococcal exposure activates CD4 + T cells and induce cell surface exposure of HIV co receptors CCR5 and CXCR4.
• Also enhances HIV infection of primary CD4 +T cells through TLR 2 activation.