304
■ SELF-STUDY ASSIGNMENTS • Identify relevant information from patient history, physical ex-
SECTION 16
1. Develop a protocol for switching patients from IV to oral therapy
when treating pyelonephritis.
2. Perform a literature search to find clinical trials comparing drug
therapy in pyelonephritis, and compare inclusion criteria, drug
regimens, outcomes, and costs of therapy.
3. Develop a clinical pathway that could be used for the manage-
ment of suspected pyelonephritis.
Infectious Diseases
CLINICAL PEARL
Pyelonephritis can be managed with many different drugs; choose
drugs that are bactericidal and cleared in the active form by the kidney.
Drugs suitable for once-daily therapy help to reduce treatment costs.
REFERENCES
1. Jinnah F, Islam MS, Rumi MA, et al. Drug sensitivity pattern of E. coli
causing urinary tract infection in diabetic and nondiabetic patients. J
Int Med Res 1996;24:296–301.
2. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial
treatment of uncomplicated acute bacterial cystitis and acute pyelone-
phritis in women. Infectious Diseases Society of America (IDSA). Clin
Infect Dis 1999;29:745–758.
3. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated
urinary tract infection. Infect Dis Clin North Am 1997;11:551–581.
4. Bailey RR, Begg EJ, Smith AH, et al. Prospective, randomized con-
trolled study comparing two dosing regimens of gentamicin/oral
ciprofloxacin switch therapy for acute pyelonephritis. Clin Nephrol
1996;46:183–186.
5. Talan DA, Stamm WE, Hooton TM, et al. Comparison of ciprofloxa-
cin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute
uncomplicated pyelonephritis in women. A randomized trial. JAMA
2000;283:1583–1590.
6. Klausner HA, Brown P, Peterson J, et al. A trial of levofloxacin 750mg
once daily for 5 days versus ciprofloxacin 400mg and/or 500mg twice
daily for 10 days in the treatment of acute pyelonephritis. Curr Med
Res Opin 2007;23:2627–2628.
7. Pinson AG, Philbrick JT, Lindbeck GH, et al. ED management of acute
pyelonephritis in women: a cohort study. Am J Emerg Med 1994;12:271–
278.
125
PELVIC INFLAMMATORY DISEASE
AND OTHER SEXUALLY
TRANSMITTED DISEASES
Frankie and Jenny Were Lovers . . . . . . . . . . . . Level II
Denise L. Howrie, PharmD
Pamela J. Murray, MD, MHP
LEARNING OBJECTIVES
After completing this case study, the reader should be able to:
amination, and laboratory data suggestive of the diagnosis of a
sexually transmitted disease (STD).
• List major complications of STDs and appropriate strategies for
prevention and/or treatment.
• Discuss other health issues that may be present in patients re-
ferred for treatment of STDs.
• Provide appropriate treatment plans for patients with STDs, in-
cluding drug(s), doses, and monitoring.
• Develop patient counseling strategies regarding drug treatment
and possible adverse effects.
PATIENT PRESENTATION
쐽 Chief Complaint
“My lady and I don’t feel good.”
쐽 HPI
Frankie Mason is a 28-year-old man who presents to a health clinic
with complaints of 5 days of painful urination and increasing
amounts of discolored urethral discharge. Today, he noted four
painful blisters on the penis. He is single, is sexually active with two
to three concurrent partners, and admits to unprotected sex “at least
once” in the past 2 weeks. He does not know the sexual histories of
his current or past sexual partners or their sexual partners. He
denies IV drug use, is heterosexual, and has no active medical
problems. He denies oral or rectal intercourse. He admits to over 15
lifetime sexual partners.
쐽 PMH
History of genital herpes 2 years ago, otherwise negative. He has not
undergone testing for HIV and has not been immunized against
hepatitis B. He is unaware of hepatitis A or C as infectious diseases,
asking “Do you get that from sex or restaurant food?”
쐽 FH
Noncontributory
쐽 SH
Denies cigarette use; has two to four beers “on weekends”; may be
unreliable in keeping follow-up appointments because he states, “I
don’t like doctors.”
쐽 Meds
None
쐽 All
Cipro (“makes me dizzy”)
쐽 ROS
Occasional headaches; denies stomach pain, constipation, vision
problems, night sweats, weight loss, or fatigue
쐽 Physical Examination
Gen
Patient is a well-developed male in NAD, very talkative
VS
BP 104/80, HR 72, RR 12, T 37.6°C; Wt 78 kg
Skin
No rashes or other lesions seen
 305
HEENT 쐽 HPI

CHAPTER 125
No erythema of pharynx or oral ulcers Jenny Klein is a 22-year-old female sexual partner of Frankie who
reports a 1-day history of increasingly severe dysuria, lower abdom-
Neck/Lymph Nodes inal pain, fever, nausea, emesis × 2, and vaginal discharge. She is
No lymphadenopathy; neck supple sexually active with “only Frankie,” has no previous history of
urinary or genital infection, and denies IV drug use. She is unaware
Chest of Frankie’s multiple sexual partners. Her last menses ended 10 days
Normal breath sounds; good air entry ago and last intercourse was 7 days ago without use of a condom.
She noted the vaginal discharge yesterday, which she describes as
CV thick and yellow. She denies oral or rectal intercourse. She admits to

Pelvic Inflammatory Disease and Other Sexually Transmitted Diseases

RRR; no murmurs three lifetime sexual partners.

Abd 쐽 PMH
No tenderness or rebound; no HSM Negative with no pregnancies. She has not been immunized against
hepatitis B or A and has not received the human papillomavirus
Genit/Rect vaccine (Gardasil), because she believes she is “low risk.”
Tanner stage V; testes descended, nontender, without erythema.
Thick gray-white urethral discharge; four small erupting vesicles on 쐽 FH
penile tip and glans; negative rectal examination; no scrotal tender- HTN in maternal grandmother; history of depression
ness or swelling. No genital growths visualized.
쐽 SH
MS/Ext
Denies nicotine or recreational drug use; occasional one to two
No inguinal or other lymphadenopathy; no lesions or rashes; glasses of wine; does not use hormonal or other contraception,
muscle strength and tone normal reports occasional use of condoms; no routine medical care
Neuro 쐽 Meds
CN II–XII intact; DTRs 2+ bilaterally and symmetric None
쐽 Urethral Smear
쐽 All
15 WBC/hpf; Gram stain (+) for intracellular Gram-negative
NKDA
diplococci (Fig. 125-1); rare flagellated organisms by saline prep
microscopy 쐽 ROS
쐽 Assessment Occasional painful menses self-treated with acetaminophen
1. Urethritis caused by gonococcal and Trichomonas infections 쐽 Physical Examination
2. Recurrent genital herpes Gen
Well-developed woman in moderate-to-severe abdominal discom-
PATIENT PRESENTATION fort

쐽 Chief Complaint VS
“I feel sick to my stomach.” BP 110/76, HR 120, RR 16, T 39.2°C; Wt 52 kg

FIGURE 125-1. Gram-negative intracellular diplococci (Neisseria gonorrhoeae).

 306
Skin Desired Outcome
SECTION 16

No rashes seen 2. State the goals of treatment for each patient.

HEENT
Therapeutic Alternatives
No erythema of pharynx or oral ulcers
3. What therapeutic options are available for treatment of each
Neck/Lymph Nodes patient?
No lymphadenopathy; neck supple
Optimal Plan
Chest
4.a. What treatment regimen (drug, dosage form, dose, schedule,
Infectious Diseases

Normal breath sounds; good air entry; breasts Tanner stage V and duration) is appropriate for these patients?
CV 4.b. What alternatives would be appropriate if the initial therapy
cannot be used?
RRR; no murmurs

Abd Outcome Evaluation

Guarding of right and mid-lower quadrants with palpation
Genit/Rect
Pubic hair Tanner stage V; vulva with no ulcers visible; moderate
erythema with mild excoriations. Vagina with large amount of thick
yellow-white discharge and mild erythema. Cervix shows erythema
and extensive yellow-white discharge from the os; no masses on
bimanual examination; cervical motion tenderness; adnexal tender-
ness and fullness. No genital growths visualized.
MS/Ext
No adenopathy, lesions or rashes; no arthritis or tenosynovitis
5.a. What clinical and laboratory parameters are necessary to eval-
uate the therapy for achievement of the desired outcome and to
detect or prevent adverse effects?
■ CLINICAL COURSE
Eight hours later, Chlamydia PCR positive test results received on
samples from both patients.
Two days later, bacterial cultures of urethral discharge (Frankie)
and vaginal secretions (Jenny) are reported positive for Neisseria
gonorrhoeae.
5.b. What changes, if any, in antibacterial therapy are required?

Neuro Patient Education

CN II–XII Intact, DTRs 2+ and symmetric bilaterally 6. What information should be provided to Frankie to enhance compli-
쐽 Labs ance, ensure success of therapy, and minimize adverse effects?

Na 138 mEq/L
K 4.2 mEq/L
Hgb 12.2 g/dL
Hct 37%
WBC 12.75 × 103/mm3
Neutros 66%
■ SELF-STUDY ASSIGNMENTS
Cl 102 mEq/L Plt 250 × 103/mm3 Bands 12% 1. Because fluoroquinolones are no longer recommended for gono-
BUN 22 mg/dL Lymphs 10%
coccal infections, research alternative options to fluroquinolones
SCr 0.9 mg/dL Monos 12%
Glu 106 mg/dL
for treatment in patients with severe drug hypersensitivity to
cephalosporins.
쐽 Other 2. Sexually active adolescents are a high risk group for development
Examination of vaginal discharge: pH 6.0, no yeast or hyphae seen; of STDs. Identify biologic, social, and psychological factors that
KOH prep negative, “whiff” test negative; flagellated organisms and affect this risk, and discuss how clinicians can assist in addressing
increased WBC seen by saline prepared microscopy; negative for some adolescent risk behaviors.
clue cells 3. Review the definitions and legal status of expedited partner therapy
(EPT) in your areas of practice. Identify and discuss legal, ethical, and
쐽 UA public health implications of this practice (see www.cdc.gov/std/ept).
Rare WBC/hpf; protein 100 mg/dL; Gram stain (–)

쐽 Assessment CLINICAL PEARLS

PID
Infection of the genital tract: cervicitis, vaginitis, and urethritis
QUESTIONS
Problem Identification
1.a. For each patient, create a list of drug therapy problems.
1.b. What information indicates the presence or severity of each
STD in each patient?
1.c. Should any additional tests be performed in these patients?
1.d. What complications of infection can be reduced or avoided
with appropriate therapy for each patient?
Quinolones such as ciprofloxacin are no longer recommended for
infections in which gonococcus may be present because of increas-
ing rates of drug resistance.
Partner notification and treatment may be enhanced through
“expedited partner therapy” strategies in which a sexual partner
receives medication(s) or prescription(s) from a patient with a docu-
mented STD, in addition to information and referral for evaluation.
REFERENCES
1. Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep
2006;55(RR-11):1–100.
 307
2. Centers for Disease Control and Prevention. Update to CDC’s sexually 쐽 HPI

transmitted diseases treatment guidelines 2006: fluoroquinolones no
longer recommended for treatment of gonococcal infections. MMWR
Morb Mortal Wkly Rep 2007;56:332–336.
3. Burstein GR, Murray PJ. Diagnosis and management of sexually trans-
mitted disease pathogens among adolescents. Pediatr Rev 2003;24:75–
82.
4. Burstein GR, Murray PJ. Diagnosis and management of sexually
transmitted diseases among adolescents. Pediatr Rev 2003;24:119–
127.
5. Geisler WM. Management of uncomplicated Chlamydia trachoma-
CHAPTER 126
Bill Baker is a 79-year-old man who has been seen by a neurologist
for benign tremors in his hands, difficulty walking, and extremity
numbness. As part of his work-up, he was found to have both a
positive RPR and FTA-ABS. The patient is not aware of any
previous syphilis tests or diagnoses. The patient is a professor at a
small university and states that he has no perceptible mental
changes.
The patient describes hand shakes for greater than 50 years. He
has had difficulty standing on one foot and walking for the last 10

Syphilis
tis infections in adolescents and adults: evidence reviewed for the years. In addition, the patient suffers from numbness in the
2006 Centers for Disease Control and Prevention. Sexually trans-
bottom of the feet that also began about 10 years before today’s
mitted diseases treatment guidelines. Clin Infect Dis 2007;44:S77–
S83.
presentation.
6. Walker CK, Wiesenfeld HC. Antibiotic therapy for acute pelvic inflam-
matory disease: the 2006 Centers for Disease Control and Prevention. 쐽 PMH
Sexually transmitted diseases treatment guidelines. Clin Infect Dis Hypertension
2007;44:S111–S122. Left ankle surgery (including placement of hardware) 2 years
7. Holland-Hall C. Sexually transmitted infections: screening, syn- ago
dromes, and symptoms. Prim Care Clin Office Pract 2006:33:433– Back surgery for leg/foot weakness 12 years ago
454.
Back surgery for leg/foot weakness 22 years ago
8. Wendel KA, Workowski KA. Trichomoniasis: challenges to appropri-
ate management. Clin Infect Dis 2007;44:S123–129.
Eye surgery 25 years ago
9. Centers for Disease Control and Prevention. Quadrivalent human
papillomavirus vaccine: recommendations of the Advisory Committee 쐽 FH
on Immunization Practices. MMWR Morb Mortal Wkly Rep Wife died of breast CA in 1983
2007;56(RR-02):1–32. Brother alive and well (age 76)
Son died in MVA in 1973
Mother died of pneumonia (age 81)
Father died of heart attack (age 66)

쐽 SH

126
Smokes a pipe (50-year history, approximately once per day)
Social alcohol usage (average four drinks per week)
Previous MSM Hx although currently no sexual contacts (no Hx of
STDs)
SYPHILIS 쐽 Meds
The Great Impostor. . . . . . . . . . . . . . . . . . . . . . .Level I Amoxicillin/clavulanic acid 875 mg po BID (prescription written
for 10 days; today is day 7/10)
Marc H. Scheetz, PharmD, MSc
Toprol XL 100 mg po daily
ASA 81 mg po daily
Ibuprofen 200 mg po Q 6 h PRN

LEARNING OBJECTIVES 쐽 All

After completing this case study, the reader should be able to:
• Discuss the diagnosis of syphilis and differentiate among the
temporal stages of the disease.
• Develop a pharmacotherapeutic treatment plan individualized
for the patient’s stage of syphilis.
• Recommend alternate treatment regimens when the primary
therapeutic option is contraindicated.
• Describe appropriate monitoring, follow-up, and counseling
of patients with a syphilitic infection to ensure success of
treatment.
PATIENT PRESENTATION
쐽 Chief Complaint
“I’ve had trouble walking for the past 10 years. Lately, it has been
getting worse.”
NKDA
쐽 ROS
General: No fever or chills; no change in weight; no change in
appetite
Skin: No generalized rash or eruptions
HEENT: No headache; no visual changes; no sore throat; no
dizziness or syncope; no head trauma; no auditory changes
Respiratory: No shortness of breath, cough, or wheezing
Cardiac: No CP or palpitations
Gastrointestinal: No NV; no abdominal pain; no diarrhea or consti-
pation
Urinary: No dysuria or increased urinary frequency; no hematuria;
no urinary incontinence
Musculoskeletal: Chronic lower back pain; no extremity swelling
Neurologic: Numbness on bottom of feet bilaterally; no Hx of
seizures or loss of consciousness
Hematologic: No history of bleeding or easy bruising
Psychiatric: No depression or anxiety