DT is a 22-year-old male (NKDA) who arrives at the college student health clinic for his annual check-up. He reports no signs or symptoms currently but has had previous episodes of burning sensation on his genitals a few months ago. His sexual history indicates he has had multiple partners, both males and females, in the past several months. He notes to having unprotected intercourse in his last sexual encounter (HIV status unknown) occurring a week ago. He has no prior PMH or medications upon looking at his medical profile. When asked about his vaccination record, DT states all his vaccinations were done during his childhood and a state database inquiry revealed his last vaccine was given when he was 9 years old.
Chlamydia and Gonorrhea testing: Negative
Urinalysis: Leukocyte esterase negative, Nitrite positive, and bacteria positive
What recommendations can you give to DT at this time?
A. Treat for a urinary tract infection with Bactrim DS 1 PO BID.
B. Due to his high risk of sexually transmitted infections, empirically treat for chlamydia and gonorrhea with Vibramycin 100 mg PO BID for 7 days and Rocephin 500 mg IM once.
C. Start Truvada plus Isentress for post exposure prophylaxis for HIV due to potential exposure from his recent sexual encounter.
D. Offer the HPV vaccine, Gardasil-9, for prevention as he qualifies.
Answer with rationale: D
Brand/generics covered: Vibramycin/doxycycline, Rocephin/ceftriaxone, Truvada/tenofovir disoproxil fumarate and emtricitabine, Isentress/raltegravir, Macrobid/nitrofurantoin monohydrate
Sexually transmitted infections (STIs) is a prevalent complication in the young, active patient population. Patients are at an increased risk for STIs and HIV due to factors such as multiple sex partners, unprotected sex, young age, and men who have sex with men (MSM). Annually screens for HIV and STIs are recommended by the CDC in these patients with risk factors.
Answer choice A is incorrect as the patient is asymptomatic for a urinary tract infection. Nitrofurantoin is a first line option for lower urinary tract infections, however, UTIs is less prevalent in healthy, young males. Male patients with genitourinary complications that impair voiding are more likely to have UTIs. The urinalysis also has the potential to be contaminated, as the colony forming units is less than 100,000 units.
Answer B is incorrect as the patient shows no signs of STIs, in particular infections of gonorrhea or chlamydia. Patients may present asymptomatic for STIs, thus cultures and/or PCR testing should be done to rule out infections. The patient had negative cultures and PCR testing, alongside no symptoms for STIs. Gonorrhea and Chlamydia are common co-infections with Rocephin and Vibramycin being the first line treatment options for these infections respectively. The RPR is more specific for syphilis and not relevant to these answer choices.
Answer choice C is incorrect as post exposure prophylaxis (PEP) is indicated within 72 hours of the sexual encounter with a potential carrier of HIV. For effective use of PEP, the HIV status (viral load and adherence to anti-retroviral therapy, ART) of the HIV positive partner and the timing of the exposure are key factors in the use PEP. Another factor to indicate the use of PEP is the absence of protection such as condoms.
Answer choice D is correct as the CDC recommends patients sexually capable patients up to the age of 45 years to receive the vaccine for Human Papillomavirus (HPV). Strains 16 and 18 of HPV has been associated with the development of cervical and penile cancers. Gardesil-9 is a vaccine that covers those subtypes and is given as a 2-dose series between the ages of 9 – 14 years at least 5 months apart from the 1st dose. Patients 15 years and older are given the 3-dose series at months 0, 2, and 6 months apart.
CDC STI Treatment Guidelines 2021
CDC HIV Post Exposure Prophylaxis
IDSA Guidelines Urinary Tract Infections
NAPLEX Competency Statements
1.2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
1.6 – Risk factors or maintenance of health and wellness
2.1 – Pharmacology, mechanism of action, or therapeutic class
2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
3.3 – Medication reconciliation; indication or therapeutic uses; lack of indication; inappropriate indication; duplication of therapy; omissions
6.4 – Vulnerable populations, special populations, or risk prevention programs"
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