eConsult Transcript
PCP submission
27 year old male who identifies as bisexual was recently with a new partner who is a gay male engaging in oral sex. The patient wrote into our online platform relaying that he had c/o swollen tonsils/sore throat and dysuria x 4 days. No penile discharge. No fever, cough or swollen cervical lymph nodes. Had a UA and urine culture with 0 wbc/hpf and completely normal culture as well as urine gc/ct naat. Also negative HIV and RPR. I ordered a throat swab for strep throat and gc/ct but it was not done as he went directly from online messaging to the lab and not to a clinic.
Given the risk, I was planning to offer 2g azithromycin as empiric tx given the risk despite negative UA and urine gc/ct
Would you agree with this plan or send to clinic for further testing (pharyngeal swab, urethral swab)?
Specialist response
Thank you for this consult, and for the summary you provided.
If this were my patient I would advise a clinic visit. Rectal and pharyngeal swabs for GC and chlamydia can be self-collected, but given his recent negative testing seems reasonable to see him in person. I think the likelihood of pharyngeal GC or chlamydia is high, and it is important to make a firm diagnosis, mostly because if he fails to improve after therapy, you need to decide how next to proceed.
In addition, persons with pharyngeal gonorrhea should be retested two weeks later to ensure the eradication of the infection. The STI guidelines have changed recently, so empiric treatment for both GC and chlamydia are different: 500 mg ceftriaxone IM (unless over 150 kg, when you’d give one full gram) plus doxycycline 100 mg po BID x 7 days. So I would propose the following: -have him come into clinic for an evaluation – get pharyngeal swabs for GC and chlamydia NAAT -empiric rx with a dose of IM ceftriaxone plus a script for oral doxycycline as above CDC guidance for GC testing, treatment and follow-up is here, just in case you want a reference:
https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm Hope this helps! Thank you for using Rubicon MD, please let me know if you have additional questions or concerns.
