2025 – PAGE 95 – OB/GYN AND SOME STDs

NEISSERIA GONORRHEA

Neisseria gonorrhea creates a smelly, greenish discharge. It is USUALLY asymptomatic, so consider this in the differential for any adolescent patient with arthritis. Treat uncomplicated infections in adolescents with IM ceftriaxone x 1. If allergic to ceftriaxone, treat with gentamicin PLUS azithromycin. Test for other STDs including chlamydia, syphilis, and HIV and treat if positive. If chlamydia co-infection has not been excluded when the patient is diagnosed with gonorrhea, then also treat presumptively for chlamydia with PO doxycycline for 7 days.

• MNEMONIC: Gonorrheais also known as “the CLAP” because on Gram stain the diplococci kind of look like two hands clapping. “C for the Clap, and C for Ceftriaxone x1.” If you are wondering about “GC,” it comes from “GonoCoccus.”
• ­DISSEMINATED GONORRHEA: Once the disease has disseminated, the local symptoms are no longer present! Look instead for a rash and joint involvement. It can also cause meningitis and endocarditis. This is an INTRACELLULAR Fitz-Hugh/PID. When suspecting disseminated gonorrhea (e.g., single pustule + swollen knee), culture any pustules as well as all orifices.
• PEARL: Treatment regimen for chlamydia and gonorrhea co-infection is IM ceftriaxone x 1 plus PO doxycycline for 7 days.

NONGONOCOCCAL URETHRITIS

Nongonococcal urethritis is usually associated with scant, mucoid discharge as opposed to the profuse, purulent discharge of gonorrhea. The differential includes Chlamydia, Ureaplasma, Mycoplasma genitalium, HSV, Trichomonas, and even adenovirus.

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID) can result in potentially serious outcomes (sepsis, infertility), so it should be treated on the basis of your clinical diagnosis. If there is no improvement on appropriate outpatient therapy and cultures are negative, obtain an ultrasound to evaluate for a tubo-ovarian abscess. Also obtain an RPR to look for syphilis and consider getting HSV PCR (not HSV titers since they are nonspecific). Treatment options depend on the setting:

• OUTPATIENT: Ceftriaxone (or Cefoxitin) x 1 + Doxycycline BID x 14 days (or AZITHROmycin x1) ± Metronidazole (optional)
• INPATIENT/IV: Cefotetan (or Cefoxitin) + Doxycycline BID. Alternatives: Clindamycin + Gentamicin, or Ampicillin-Sulbactam + Doxycycline. Inpatient therapy is reserved for patients who are pregnant, have intractable nausea and vomiting, have high fever, or have failed outpatient therapy.

FITZ-HUGH CURTIS SYNDROME (AKA PERI-HEPATITIS)

FITZ-HUGH CURTIS SYNDROME (AKA PERI-HEPATITIS) is due to Gonorrhea or Chlamydia and occurs after an episode of PID. The major symptoms include sudden right upper quadrant (RUQ) abdominal pain aggravated by breathing, coughing or movement. Pain can be referred to the right shoulder. LFTs are NORMAL. Do a pelvic exam and obtain cultures if this is suspected. Do NOT order LFTs as your next step.