SAEM Clinical Images Series: A Rare Cause of Recurrent UTI

bulge

A 52-year-old male presents to the Emergency Department with a chief complaint of right lower abdominal pain with urinary frequency and urgency over the past week. The pain radiates from his right groin with 10/10 severity at times. He reports multiple diagnoses of urinary tract infections over the last year requiring oral antibiotics. He claims intermittent constipation, denies any trauma, and is a truck driver by trade.

Vitals: T 97.7 °C; BP 138/75; HR 75; RR 16; O2 sat 96%

General: WDWN obese male, A/O x4, in mild distress

Abdomen: Soft, nondistended, normoactive bowel sounds, no organomegaly. A 5 cm moderately tender soft tissue bulge suggestive of a direct hernia is palpated in the right inguinal area and is reduceable.

Complete blood count (CBC): Within normal limits

Complete metabolic panel (CMP): Within normal limits

Urinalysis (UA):

  • Color: Cloudy, yellow
  • Blood: Trace
  • Leukocyte esterase: Positive
  • Nitrite: Positive
  • WBCs: 15-30 hpf
  • RBCs: 3-5 hpf
  • Bacteria: Moderate

This patient’s CT scans demonstrate an inguinal herniation of the urinary bladder, which occurs in less than 4% of all inguinal hernias. The clinical finding of a soft tissue mass in the groin in the setting of recurrent urinary tract infections should include urinary bladder herniation in the differential diagnosis.

Oral or parenteral antibiotics based on clinical presentation and prevalent sensitivities should be given to address urinary tract infections. Emergent or non-emergent (if reduceable) surgical consultation, usually by a urologist, is standard. Surgical reduction and repair techniques that utilize mesh versus non-mesh have been associated with a better prognosis with less recurrence.

Take-Home Points

  • Although rare, an inguinal herniation of the urinary bladder should be considered in males over 50 years old who have a herniation on physical exam and urinary complaints.
  • Risk factors include obesity, BPH, and male sex. This condition is diagnosed in very few women.
  • Computerized tomography is the usual imaging modality to diagnose a urinary bladder herniation.
  • Patients may be asymptomatic or have symptoms that may include inguinal pain or swelling, urinary retention, and acute renal failure.
  • Manual compression of hernia to void is pathognomonic for a urinary bladder herniation.

  • Branchu B, Renard Y, Larre S, Leon P. Diagnosis and treatment of inguinal hernia of the bladder: a systematic review of the past 10 years. Turk J Urol. 2018 Sep;44(5):384-388. doi: 10.5152/tud.2018.46417. Epub 2018 Sep 1. PMID: 30487042; PMCID: PMC6134980.
  • Papatheofani V, Beaumont K, Nuessler NC. Inguinal hernia with complete urinary bladder herniation: a case report and review of the literature. J Surg Case Rep. 2020 Jan 2;2020(1):rjz321. doi: 10.1093/jscr/rjz321. PMID: 31911827; PMCID: PMC6939942.

By |2023-10-06T13:25:23-07:00Oct 6, 2023|Genitourinary, SAEM Clinical Images|

Trick of Trade: Dual Foley catheter to control massive epistaxis

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

dual balloon for massive epistaxis

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

  1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
  2. Inflate the balloon partially with 15-20 cc of air.
  3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
  4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

Reference

  1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020

Trick of Trade: Removal of Entrapped Metal Zipper

zipper entrapment injury

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

zipper anatomy

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

  • Cut the sliding mechanism (aka the endplate) using metal cutters.
  • Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
  • Use mineral oil for lubrication.
  • Use lateral compression technique to relieve the tension on the trapped skin.
  • Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

  • Lidocaine gel
  • Blade or scissors

Technique

  1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
  2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
  3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
  4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
  5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

metal zipper cut trick zipper entrapment

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

metal zipper entrapped free

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?

References

  1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.

SAEM Clinical Images Series: An 8-year-old Male with Dysuria

dysuria

An 8-year-old Caucasian male with no significant past medical history presented to the pediatric emergency department (ED) with complaints of three days of abdominal pain and dysuria, accompanied by nausea, vomiting, and poor oral intake. The patient had previously presented to his pediatrician, where he was found to have microscopic hematuria and subsequently sent to the ED. Microscopic hematuria and increased abdominal pain in the ED prompted a point of care ultrasound (POCUS).

GI: Soft on palpation, normal bowel sounds, tender to palpation at midline below the umbilicus.

GU: No trauma or erythema of the penis.

Remaining exam wnl.

Urinalysis (UA): Yellow; Cloudy; Ketones: 15; Protein >=300; Leukocyte esterase: large; Nitrite: positive; WBC/HPF: Packed; RBC/HPF:51-100

Urine Culture: >100,000 staphylococcus CFU/mL

The most likely site of abnormality in this patient is the urethra. Image 1 shows massive bilateral hydronephrosis while image 2 shows hydroureter and bladder wall thickening. This presentation in a male, together with the lab findings suggestive of a UTI, should raise concerns for posterior urethral valves (PUV). PUV, a congenital obstruction of the urethra, is one of the most common causes of lower urinary tract obstruction in males. [1]

The next step in management for patients with probable PUV is a referral to a urologist for a voiding cystourethrogram (VCUG) and cystoscopy to assess for vesicoureteral reflux and valvular obstruction. Patients who are found to have PUV can then undergo incision and correction of the urethral valve. PUV typically presents in the newborn period in males with a poor urinary stream, urinary tract infections, and other voiding complaints and can be corrected with bladder catheterization or valvular ablation [1,2].

Take-Home Points

  • While rare, PUV should be considered in the differential for any pediatric patient presenting with urinary tract-related complaints, abdominal pain, and unexplained nausea or vomiting, particularly in school-aged males.
  • A school-aged male without an underlying diagnosis presenting to the hospital with a UTI should prompt clinicians to look for underlying predisposing conditions, such as PUV – an undertaking in which bedside ultrasound can be extremely useful.
  • Point of care ultrasound (POCUS) is a tool used in real time by emergency physicians to provide evidence for hydronephrosis, which can lead to the diagnosis of PUV.

  • Hodges SJ, Patel B, McLorie G, Atala A. Posterior urethral valves. ScientificWorldJournal. 2009 Oct 14;9:1119-26. doi: 10.1100/tsw.2009.127. PMID: 19838598; PMCID: PMC5823193.
  • Shields LBE, White JT, Mohamed AZ, Peppas DS, Rosenberg E. Delayed Presentation of Urethral Valves: A Diagnosis That Should Be Suspected Despite a Normal Prenatal Ultrasound. Glob Pediatr Health. 2020 Oct 15;7:2333794X20958918. doi: 10.1177/2333794X20958918. PMID: 33117862; PMCID: PMC7570289.

SAEM Clinical Image Series: Inguinal Masses

A 50-year-old female with a past medical history of gastritis and marijuana abuse presents to the Emergency Department (ED) with epigastric abdominal pain for one day. The patient reports she was seen in the ED one month prior for similar symptoms and had an ultrasound of the gallbladder, which was negative. She was discharged home with prescriptions for Pepcid, Carafate, and Zofran. Once discharged home she did not experience any symptoms until the day prior to presenting again to the ED. The patient denies nausea, vomiting, back pain, dysuria, hematuria, subjective fevers, chills, diarrhea, vaginal bleeding, vaginal discharge, chest pain, or shortness of breath. Of note, the patient also reports intermittent bilateral inguinal discomfort, stating she believed she had inguinal hernias, which would become tender without exertion or any notable inciting factor.

Vitals: HR 82; T 97.1°F; BP 147/95; RR 20; O2 sat 100% on room air

General: No acute distress

Cardiovascular: Regular rate and rhythm; no murmur; bilateral upper extremity and lower extremity pulses palpable

Gastrointestinal: Soft; generalized tenderness, predominantly epigastric; no abdominal masses

Genitourinary: Pelvic exam deferred; normal external vaginal exam; bilateral inguinal masses, non-tender, no overlying cellulitis

White blood cell (WBC) count: 5.64 k

Hemoglobin (Hgb): 10.4 g/dL

Hematocrit (Hct): 33.0%

Platelet count: 279 k

Complete metabolic panel (CMP): Unremarkable

Urine pregnancy test (UPT): Negative

DDX: Bilateral inguinal hernias, abscess, undescended testicles.

The abnormal findings in this patient were consistent with undescended rudimentary testicles in a patient without a prior diagnosis of true hermaphroditism (an ovotesticular disorder of sex development [DSD]). Our patient was phenotypically a female, with developed breasts, vagina, uterus, and ovaries, although uterus and ovaries were noted to be diminutive on imaging. Our patient identified herself as a female of homosexual orientation.

True hermaphroditism is characterized as the presence of seminiferous tubules and ovarian follicles in the same individual. Genitalia is usually ambiguous; however, patients may appear phenotypically male or female. Reproductive organ differentiation is a complex process involving multiple pathways and receptors, predominantly antimüllerian hormone (AMH). When testes differentiate, the secretion of AMH will lead to regression of müllerian structures, and lack of AMH will result in progression of female organ development (e.g., fallopian tubes, uterus, cervix, and upper vagina). The vast majority of patients with hermaphroditism will have a uterus or uterine horn, and most patients have breast development, ovulation, and menstruation.

Patients should be educated about the importance of close follow-up and the possible complications involved with this diagnosis. Although some patients may be asymptomatic and therefore undiagnosed, undescended testicles are at a slightly increased risk for gonadal tumors and may also suffer from testicular torsion. Patients may need to have a biopsy of undescended testes to confirm testicular tissue and be required to have surgical removal of testes.

Take-Home Points

  • The differential diagnosis for bilateral inguinal masses in a phenotypically female patient includes undescended testicles.
  • Patient education is of utmost importance as undescended testicles are still at risk of testicular torsion and carry an increased risk of testicular cancer.

  • English RE, Tulloch DN, Blaquiere RM. The demonstration of true hermaphroditism by computed tomography. Clin Radiol. 1986 Nov;37(6):593-4. doi: 10.1016/s0009-9260(86)80035-6. PMID: 3791859.
  • van Niekerk WA, Retief AE. The gonads of human true hermaphrodites. Hum Genet. 1981;58(1):117-22. doi: 10.1007/BF00284158. PMID: 6895206.
  • Walker AM, Walker JL, Adams S, Shi E, McGlynn M, Verge CF. True hermaphroditism. J Paediatr Child Health. 2000 Feb;36(1):69-73. doi: 10.1046/j.1440-1754.2000.00432.x. PMID: 10723695.
  • White, P. C. (2012). Disorders of Sexual Development. In Goldman’s Cecil Medicine (pp. 1511–1519). Elsevier. https://doi.org/10.1016/B978-1-4377-1604-7.00241-4

 

By |2022-01-01T23:43:19-08:00Jan 3, 2022|Genitourinary, SAEM Clinical Images|

SAEM Clinical Image Series: Pediatric Penis Swelling

A 3-year-old healthy uncircumcised male presents to the Emergency Department with five days of penis swelling and pain. Five days prior, his father noted that the patient’s foreskin appeared stuck behind the head of the penis. The patient was seen at an urgent care facility four days prior and was given an antifungal cream for presumed balanitis, however, this did not resolve the patient’s symptoms. Since that time, the penis has been getting progressively more swollen and painful. The patient has not experienced the inability to urinate, decreased urine output, penile discharge, other penile lesions, fever, chills, abdominal pain, nausea, vomiting, testicular pain, or testicular swelling.

Vitals: Within normal limits

General: Alert, anxious

Genitourinary: Penile swelling, erythema, and tenderness to palpation

Non-contributory

Paraphimosis is a medical emergency due to the risk of tissue necrosis. A preputial or phimotic ring – a circumferential band of tissue – caught behind the glans causes swelling of penile tissue.

In the evaluation of painful penile swelling, the first step is to determine whether the patient is circumcised or not through a review of the medical record or discussion with the patient’s family. In an uncircumcised male, the critical next step is to assess for an entrapped and retracted foreskin (paraphimosis). Visualization of the glans penis and the urethral meatus as in this case demonstrates that the foreskin is retracted. Additionally, visualization of the glans penis and urethral meatus makes a scarred and unretractable foreskin (pathologic paraphimosis) unlikely to be the primary diagnosis. The differential diagnosis also includes hair tourniquet syndrome, chigger bites, and inflammation of the glans and foreskin (balanitis and balanoposthitis).

Take-Home Points

  • In any male presenting with penile pain, it is critical to first ascertain his circumcision status. In an uncircumcised male, visualizing the glans and urethral meatus demonstrates that the foreskin is retracted.
  • Paraphimosis is a medical emergency caused by an entrapped, retracted foreskin.
  1. Bragg BN, Kong EL, Leslie SW. Paraphimosis. 2021 May 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083645.
  2. 2. Simonis K, Rink M. Paraphimosis. In: Urology at a Glance. Springer Berlin Heidelberg; 2014:361-364. doi:10.1007/978-3-642-54859-8_65

 

 

 

By |2021-09-13T10:34:13-07:00Sep 13, 2021|Genitourinary, Pediatrics, SAEM Clinical Images|

Doxycycline vs Azithromycin: Think Twice About the 2020 CDC Guideline Update on Treatment of Gonorrhea and Chlamydia

cdc gonorrhea chlamydia doxycycline

When the new Centers for Disease Control and Prevention (CDC) recommendations1 regarding the treatment of uncomplicated gonorrhea (and indirectly chlamydia) debuted like a slice of antibiotic resistance doom, it felt like another “gift” had arrived from 2020. Intramuscular (IM) ceftriaxone dosing has increased from 250 mg to 500 mg (or 1 g for weight ≥150 kg). Empiric chlamydia coverage switched from a single dose of 1 g of azithromycin to doxycycline 100 mg PO BID for 7 days. Being deferential to CDC expertise, many providers accepted them uncritically. Compliance rates with a switch from a 1-time to a 7-day regimen are not addressed, especially worrisome for a condition that can be minimally or asymptomatic. 

Case

A young woman presents with new and concerning discharge after an unprotected encounter. Her pregnancy test is negative. After agreement for empiric treatment, the patient then refuses empiric treatment when told about the new guidelines (2 injections and 14 chances for esophagitis). Patient specifically asks for the old regime or will just leave against medical advice.

Why a higher dose of ceftriaxone for gonorrhea?

It is important to note that the evidence of ceftriaxone, cefixime, and azithromycin resistance for gonorrhea is substantial.2 Observational data from across the United States and world demonstrate worsening resistance patterns. Many of our pharmacy colleagues are working on obtaining 500 mg/2 mL ceftriaxone for injection vials, so it can be given in single injection (or two for morbidly obese patients). While this guideline may be existentially troubling, this change is practically feasible and should become standard of care.

Read more about the Trick of the Trade on administering IV instead of IM ceftriaxone for gonorrohea.

Why no mention of the single-dose azithromycin option for chlamydia?

The evidence basis for the change to doxycycline for treatment of chlamydia co-infection coverage is substantially weaker. It is also decidedly mute on the risks of partial or non-compliance with treatment. The question then becomes: How profound is the treatment effect and how does it balance against its risks?

The guideline states, as evidence for the doxycycline switch:

“A recent investigation comparing children who received twice-yearly azithromycin with children who received placebo found that the gut’s resistome, a reservoir of antimicrobial resistance genes in the body, had increased determinants of macrolide and nonmacrolide resistance, including beta-lactam antibiotics, among children receiving azithromycin (10).3 A higher proportion of macrolide resistance in nasopharyngeal Streptococcus pneumoniae was demonstrated in communities receiving mass administration of oral azithromycin (11).4 Azithromycin resistance has been demonstrated in another STI, Mycoplasma genitalium, and sexually transmissible enteric pathogens (e.g., Shigella and Campylobacter) (12–14)5-7. In addition, evidence supports increasing concern for the efficacy of azithromycin to treat chlamydial infections, especially rectal infections (15,16)8,9.”

Citations 10 and 11 speak in generalities of resistance patterns, with citation 11 being a secondary analysis of a mass azithromycin treatment trial of young children in Niger. Citations 12-14 discuss rates of coinfection treatment failure – an important consideration, but only secondarily relevant. That leaves 2 citations (15 and 16)– one a meta-analysis and one a small poster that isn’t even available online related to known anorectal chlamydia.

That really leaves the meta-analysis8 to answer our question: how best do we protect the reproductive health of our patients in the setting of diagnostic uncertainty?

The meta-analysis

The meta-analysis is somewhat messy with substantial heterogeneity in many relevant subgroups.8 A single study comprises the majority of the evidence that shows doxycycline superiority in non-gonococcal urethritis.10 It was from 2011 and revealed that while doxycycline may be better for chlamydia treatment, azithromycin was better for coinfection treatment (such as shigella or mycoplasma). And to top the whole thing, the doxycycline superiority line reads:

“We found a pooled efficacy difference in favor of doxycycline of 1.5%… to 2.6%.”

In men with symptomatic urethritis, the superiority of doxycycline increases to 7% (an NNT of 14). If you ignore the heterogeneity and pool everyone, we arrive with an overall NNT for doxycycline over azithromycin of 38 (fixed effects model size was a 2.6% advantage). If the above study10 was removed, the pooled difference would have been non-significant with an NNT of at least 50.

Having thought perhaps they just didn’t include all the evidence, a secondary literature review was undertaken. A few small case studies11 and older observational studies12,13 were found, which showed a potential treatment failure rate of azithromycin of up to 8%, but comparable rates with doxycycline.12 That’s it. There is also genuine concern that use of azithromycin may induce resistance not only for itself but other antibiotic classes3,4 but this concern is based on fecal biome sampling from toddlers and requires a couple of steps to be relevant to our question. Doxycycline, an essential medication in its own right, for treatment of tick-borne disease, ascending genital tract infections, COPD exacerbation and MRSA, also requires our stewardship.

Medication compliance questions

Given patient non-compliance with filling and completing ED prescriptions approach rates of 20%,14,15 the recommendation for a 7-day course of doxycycline for chlamydia over single-dose azithromycin is fraught with peril. Additionally, consider that the patient may be relatively asymptomatic, placing them even more at risk for medication non-compliance for the 7-day course of doxycycline. Contrast this with the risks of pelvic inflammatory disease and infertility if untreated.

Conclusion

Given the sparse, heterogenous literature, we should have strong reservations about recommending doxycycline for patients for whom chlamydia has not been excluded. New gonorrhea treatment recommendations should be followed and efforts made to stock appropriate concentrations of ceftriaxone. A single-dose of azithromycin may be a reasonable alternative for your patient for non-gonococcal disease, after considering and discussing the risks and benefits. Pregnant patients require close follow up but should also continue to receive azithromycin.

If you are prescribing doxycycline, remember:

  • Each pill should be taken with 6-8 oz of liquid, water preferred. 
  • If taken with food, it decreases the risk of dyspepsia.
  • One should sit upright for 30 minutes following each pill, especially those with history of GERD.
  • If substantially sunexposed, sunscreen or full skin coverage should be recommended to prevent photosensitive reactions (which can be mild to quite severe).

If you are prescribing azithromycin, remember:

  • Azithromycin can cause clinically significant increases of QTc even with a single dose, but typically only to those with multiple risk factors.16 Consider ECG if patient on QTc prolonging medications and/or coexisting electrolyte derangements discovered.
  • The risk of treatment failure for chlamydia and other non-gonococcal coinfections is real. For men with symptomatic urethritis, that risk is substantially higher.
  • Have a shared decision discussion about doxycycline versus azithromycin.
  • While all patients should receive verbal and written follow-up instructions, close follow up should be emphasized, given that you are essentially contravening a CDC guideline.

Patient case resolution

You explain to your patient that the new guidelines should be followed for gonorrhea, and so she receives 500 mg of IM ceftriaxone. While the new guideline for doxycycline MAY be slightly more effective for the treatment of chlamydia, using shared decision making, she receives the old regimen (single-dose azithromycin). You verbally emphasize and document in the discharge instructions the importance they follow up with either their PCP, gynecologist, or the local sexually transmitted infection clinic for a recheck, if their symptoms don’t resolve within 7 days.


References

  1. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon
  2. https://www.cdc.gov/std/treatment-guidelines/toe/GCEvidenceTables2020.xlsx [Download file link]
  3. Doan T, Worden L, Hinterwirth A, et al. Macrolide and nonmacrolide resistance with mass azithromycin distribution. N Engl J Med 2020;383:1941–50. PMID 33176084
  4. Doan T, Arzika AM, Hinterwirth A, et al.; MORDOR Study Group. Macrolide resistance in MORDOR I—a cluster-randomized trial in Niger. N Engl J Med 2019;380:2271–3. PMID 31167060
  5. Bachmann LH, Kirkcaldy RD, Geisler WM, et al. Prevalence of Mycoplasma genitalium infection, antimicrobial resistance mutations and symptom resolution following treatment of urethritis. Clin Infect Dis 2020;ciaa293. Epub March 18, 2020. PMID 32185385
  6. Yousfi K, Gaudreau C, Pilon PA, et al. Genetic mechanisms behind the spread of reduced susceptibility to azithromycin in Shigella strains isolated from men who have sex with men in Québec, Canada. Antimicrob Agents Chemother 2019;63:e01679–18. PMID 30455248
  7. Gaudreau C, Pilon PA, Sylvestre JL, Boucher F, Bekal S. Multidrug-resistant Campylobacter coli in men who have sex with men, Quebec, Canada, 2015. Emerg Infect Dis 2016;22:1661–3. PMID 27533504
  8. Kong FY, Tabrizi SN, Law M, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014;59:193–205. PMID 24729507
  9. Dombrowski JC, Wierzbicki MR, Newman L, et al. A randomized trial of azithromycin vs. doxycycline for the treatment of rectal chlamydia in men who have sex with men. Presented at the National STD Prevention Conference, Atlanta, GA: September 14–24, 2020.
  10. Schwebke JR, Rompalo A, Taylor S, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens randomized clinical trial. Clin Infect Dis. 2011 Jan 15;52(2):163-70. PMID 21288838
  11. Bhengraj AR, Vardhan H, Srivastava P, Salhan S, Mittal A. Decreased susceptibility to azithromycin and doxycycline in clinical isolates of Chlamydia trachomatis obtained from recurrently infected female patients in India. Chemotherapy. 2010;56(5):371-7. PMID 20938174
  12. Golden MR, Whittington WL, Handsfield HH, Hughes JP, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. New Engl J Med. 2005 Feb 17;352(7):676-85. PMID 15716561
  13. Fortenberry DJ, Brizendine EJ, Katz BP, et al. Subsequent Sexually Transmitted Infections Among Adolescent Women With Genital Infection Due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. Sex Transm Dis. 1999 Jan 1;26(1):26-32. PMID 9918320
  14. Saunders CE. Patient compliance in filling prescriptions after discharge from the emergency department. Am J Emerg Med. 1987 Jul 1;5(4):283-6.
  15. Ho J, Taylor DM, Cabalag MS, Ugoni A, Yeoh M. Factors that impact on emergency department patient compliance with antibiotic regimens. Emerg Med J. 2010 Nov 1;27(11):815-20. PMID 20513734
  16. Hancox JC, Hasnain M, Vieweg WV, et al. Azithromycin, cardiovascular risks, QTc interval prolongation, torsade de pointes, and regulatory issues: a narrative review based on the study of case reports. Ther Adv Infect Dis. 2013 Oct;1(5):155-65. PMID 25165550

By |2021-01-11T14:32:02-08:00Jan 13, 2021|Genitourinary, Infectious Disease|
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