2014 PATIENT HISTORY How would you diagnose and screen Miranda? How would you treat Miranda? Are there any additional steps you would take? Antimicrobial Resistance in N. gonorrhoeae – A Case Study Miranda is a 20 year old student who will be returning home in the next few days for a summer job. She became sexually involved with a new partner about a month ago. She has no family physician. She reports her LNMP being 2 weeks ago, abnormal vaginal discharge, pain during intercourse, and that these symptoms appeared 5-7 days ago.

2014 Antimicrobial Resistance in N. gonorrhoeae – A Case Study DIAGNOSIS Any patient with lower abdominal pain should receive a complete pelvic examination Perform a complete abdominal and pelvic examination (including speculum and bimanual examinations) Given high rates of concomitant gonorrhea and chlamydial infection, specimens should be taken for both Take endocervical swabs for gonorrhea and chlamydia She is symptomatic (potential PID). Culture allows for antimicrobial susceptibility testing and is important for contact tracing Conduct NAAT (for both) and culture (for gonorrhea) Colonisation can occur without anal penetration Take rectal swabs, either culture or validated NAAT Recommendation Rationale

2014 Antimicrobial Resistance in N. gonorrhoeae – A Case Study She is symptomatic Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 gram PO in a single dose TREATMENT Miranda requires presumptive treatment Recommendation Rationale Follow-up is not assured as she is leaving town for the summer Patients should be treated with combination therapy (two antibiotics)

2014 Antimicrobial Resistance in N. gonorrhoeae – A Case Study Infection with one STI increases the chance of others being present HIV transmission and acquisition is enhanced in people with gonococcal infections Counsel Miranda on prevention Any partner within 60 days prior to symptom onset should be: Notified Tested Empirically treated regardless of clinical findings and without waiting for test results. COUNSELLING

2014 REPORTING Report the case to local public health authorities Antimicrobial Resistance in N. gonorrhoeae – A Case Study Treatment failure should also be reported Repeat screening for individuals with gonococcal infection is recommended 6 months post-treatment Strongly encourage Miranda to return to repeat her test