Answer to Q2The 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?