Case Study

A 22-year-old woman comes to your office for her routine well-woman examination. She says that she is currently sexually active in a long-term monogamous relationship. She had a chlamydial infection two years ago. Her only concern today is that her menstrual period is late.

Case Study Questions

1. Based on information from the U.S. Preventive Services Task Force (USPSTF), which one of the following statements is correct in relation to the patient’s care?

   A. Local patterns of gonorrhea infection should not affect whether you screen for gonorrhea infection.

   B. Vaginal culture is not an accurate gonorrhea screening test.

   C. Even if the patient did not have a history of chlamydia, she is at increased risk for gonorrhea infection.

   D. You will need to perform a pelvic examination to adequately screen the patient for gonorrhea infection.

   E. If a gonorrhea screening test is performed, there is no need to perform a chlamydia screening test.

2. The patient’s urine test for pregnancy is positive. Which one of the following statements about gonorrhea screening during pregnancy is correct?

   A. The USPSTF recommends screening all pregnant women for gonorrhea infection at an early prenatal visit.

   B. The definition of increased risk is different for pregnant women than for nonpregnant women.

   C. Gonorrhea infection is not associated with adverse pregnancy outcomes.

   D. Infants of women with negative third trimester gonorrhea screening tests do not need ocular prophylaxis.

   E. There is a low prevalence of gonorrhea infection in pregnant women without risk factors.

3. If the patient’s gonorrhea screening test is positive, which of the following actions is/are appropriate next steps?

   A. Arrange testing or presumptive treatment for the patient’s sexual partner.

   B. Treat the patient with a third-generation cephalosporin.

   C. Consider a second gonorrhea screening test during the third trimester.

   D. Delay treatment until the second trimester.

Answers

1. The correct answer is C

The USPSTF recommends that physicians screen all sexually active women for gonorrhea infection if they are at increased risk for infection. The USPSTF considers all women younger than 25 years to be at increased risk for gonorrhea infection. Thus, the patient’s age is the primary factor to consider when deciding to screen her. Additional risk factors for gonorrhea include a history of sexually transmitted infection, new or multiple sex partners, inconsistent condom use, sex work, and drug use.

Recognizing that individual risk for gonorrhea depends on local epidemiology of the disease, the USPSTF notes that in communities with high prevalence rates, broader screening may be warranted. Similarly, in areas with low community prevalence of gonorrhea infection, more targeted screening may be appropriate. The USPSTF encourages physicians to work with local public health authorities to identify populations at increased and decreased risk within their communities and to report all cases of gonorrhea to public health authorities to allow for more accurate estimations of gonorrhea prevalence.

Vaginal culture remains an accurate screening test when transport conditions are suitable. Nucleic acid probes have demonstrated improved sensitivity and comparable specificity when compared with cervical cultures, and some newer tests may be used with urine and vaginal swabs, enabling screening without a full pelvic examination.

Although patients with gonorrhea should be tested for or presumptively treated for chlamydia, screening for gonorrhea infection is not an acceptable screening strategy for chlamydia. Women at risk for gonorrhea and chlamydia infections should be screened for both.

2. The correct answer is E

The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in pregnant women who are not at increased risk of infection. The USPSTF could not determine the balance of benefits and harms of screening in this population because it has a low prevalence of infection.

The USPSTF recommends, however, that physicians screen pregnant women for gonorrhea infection if they are at increased risk for infection. Risk factors for pregnant women are the same as for nonpregnant women (see answer no. 1).

Gonorrhea infection during pregnancy is associated with adverse outcomes including chorioamnionitis, premature rupture of membranes, and preterm labor.

Screening is recommended at the first prenatal visit for pregnant women who are in a high-risk group for gonorrhea infection. For pregnant patients who are at continued risk, and for those who acquire a new risk factor, screening also should be conducted in the third trimester.

The USPSTF strongly recommends prophylactic ocular topical medication for gonococcal ophthalmia neonatorum for all newborns. There is good evidence that blindness caused by gonococcal ophthalmia neonatorum has become rare in the United States since the implementation of universal prophylaxis of infants.

3. The correct answers are A, B, and C

In order to prevent recurrent gonorrhea transmission, sexual partners of infected persons should be tested and treated if infected, or treated presumptively.

Genital gonorrhea infections in men and nonpregnant women may be treated with a third-generation cephalosporin (intramuscular ceftriaxone [Rocephin]) or fluoroquinolone antibiotic. Pregnant women with gonorrhea infections should be treated with a third-generation cephalosporin. Women who continue to be at high risk for infection or who develop a new risk factor during pregnancy should be screened during the third trimester. There is no indication for delaying gonorrhea treatment during pregnancy.