NUR 635 Topic 13 DQ 1

Sample Answer for NUR 635 Topic 13 DQ 1 Included After Question

David is a 19-year-old male who has been sexually active with multiple partners in the last month. The patient presents to the clinic with painful urination, swelling in testicles, and purulent discharge from his penis. David has been diagnosed with gonorrhea. Discuss the following:

  • Briefly describe the bacteria associated with gonorrhea. Include which bacteria are associated with the highest prevalence and how these bacteria are classified (e.g., gram-negative, gram-positive, etc.)
  • Determine a treatment strategy for David. Include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action. 
  • Determine monitoring, side effects, and drug-drug interactions associated with each medication.
  • The FNP seeing David also wants to cover co-treatment for chlamydia. Explain the rationale for co-treatment of chlamydia and gonorrhea.
  • How does this change your treatment strategy for David? Include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action. 
  • Determine monitoring, side effects, and drug-drug interactions associated with each medication.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.2, 2.2, 2.5. 4.2, 6.4, 9.2

A Sample Answer For the Assignment: NUR 635 Topic 13 DQ 1

Title: NUR 635 Topic 13 DQ 1

Briefly describe the bacteria associated with gonorrhea. Include which bacteria are associated with the highest prevalence and how these bacteria are classified (e.g., gram-negative, gram-positive, etc.)

Neisseria gonorrhoeae, the causative agent of gonorrhoea, is a Gram negative, coffee-bean shaped facultative intracellular diplococcus bacterium, the classical sexually transmitted bacteria (Yeshanew & Geremew, 2018). 

Determine a treatment strategy for David. Include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action. 

Because of increasing resistance to cephalosporins, preferred treatment now consists of a combination of two drugs: ceftriaxone intramuscular(IM) plus azithromycin oral (PO) (Rosenthal & Burchum, 2020). In adults, it is recommended to take Ceftriaxone, 1 g IM or IV every 24 h, plus azithromycin, 1 g PO once (Rosenthal & Burchum, 2020). 

Determine monitoring, side effects, and drug-drug interactions associated with each medication.

Pharmacokinetic parameters of ceftriaxone are highly variable in clinical situations such as severe renal insufficiency, liver and renal insufficiency, the elderly, the neonates less than 1 week of age and critically ill patients. In these clinical situations associated or not with high minimal inhibitory concentration (MIC) level, the relationship concentration-clinical outcome based on the ratio between trough plasma concentration and MIC can allow a dose adjustment. Consequently, therapeutic drug monitoring (TDM) of ceftriaxone could be possibly useful in these situations, whereas the necessity of TDM has still to be demonstrated to monitor toxicity (Dailly et al., 2012). 

Common side effects are, black, tarry stools, chest pain, chills, cough, fever, painful or difficult urination, shortness of breath, sore throat, sores, ulcers, or white spots on the lips or in the mouth, swollen glands, unusual bleeding or bruising, and unusual tiredness or weakness (Mayo Clinic, 2023). 

The FNP seeing David also wants to cover co-treatment for chlamydia. Explain the rationale for co-treatment of chlamydia and gonorrhea.


The FNP is recommending co-treatment for chlamydia due to, chlamydial and gonococcal infections in men are often asymptomatic; however, gonorrhea is more likely than chlamydia to cause symptoms in men than in women. Both types of infection can increase risk of acquiring or transmitting HIV (USPSTF, 2021).

How does this change your treatment strategy for David? Include the drug, dose, frequency, and treatment length, and explain your rationale for choosing this medication, including spectrum of coverage and mechanism of action. 

Based on review of recent evidence, CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded (CDC, 2020). 

Determine monitoring, side effects, and drug-drug interactions associated with each medication.

There are no standard routine tests to monitor the use of doxycycline. The most significant side effect is hepatic injury, which can be avoided by administering doxycycline hyclate at the recommended dosage and keeping contraindications and adverse effects in mind.  Common reactions include, mild diarrhea, photosensitivity, nausea, vomiting, skin rash/itching, headaches and tooth discoloration. There is limited evidence for severe reactions, however, they include, bloody diarrhea, leukopenia, migraines, hemolytic anemia, throat irritation or trouble swallowing, chest pain, exacerbation of systemic lupus erythematosus, shortness of breath, irregular or fast heart rate, dysuria, intracranial hypertension and esophagitis/esophageal ulcerations if taken without water (Patel & Parmar, 2023). 

Reference:

Centers for Disease Control and Prevention. (2020, December 17). Update to CDC’s treatment guidelines for gonococcal infection, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm 

Dailly E, Verdier MC, Deslandes G, Bouquié R, Tribut O, Bentué-Ferrer D. Niveau de preuve du suivi thérapeutique pharmacologique de la ceftriaxone [Level of evidence for therapeutic drug monitoring of ceftriaxone]. Therapie. 2012 Mar-Apr;67(2):145-9. French. doi: 10.2515/therapie/2012018. Epub 2012 Aug 2. PMID: 22850101.

Mayo Clinic. (2023, February 1). Ceftriaxone (injection route) side effectshttps://www.mayoclinic.org/drugs-supplements/ceftriaxone-injection-route/side-effects/drg-20073123 

Patel RS, Parmar M. Doxycycline Hyclate. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555888/

Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Elsevier Health Sciences.

US Preventive Services Taskforce. (2021, September 14). Chlamydia and gonorrhea: Screening. Recommendation: Chlamydia and Gonorrhea: Screening | United States Preventive Services Taskforce. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening 

Yeshanew AG, Geremew RA. Neisseria Gonorrhoae and their antimicrobial susceptibility patterns among symptomatic patients from Gondar town, north West Ethiopia. Antimicrob Resist Infect Control. 2018 Jul 17;7:85. doi: 10.1186/s13756-018-0376-3. PMID: 30026943; PMCID: PMC6050735.

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A Sample Answer 2 For the Assignment: NUR 635 Topic 13 DQ 1

Title: NUR 635 Topic 13 DQ 1

The sexually transmitted illness Neisseria gonorrhoeae, which is only found in humans, is an obligatory human pathogen that typically causes urethritis in males and cervicitis in women. Bacteria classified as obligatory pathogens are those that need to cause illness in order to spread from one host to another. These bacteria need to infect a host in order to live; they are unable to do it on their own (Springer C., & Salen P. (2023). In addition, gonorrhea, according Garcia et al. (2023). Neisseria gonorrhoeae are diplococci bacteria that are gram-negative. After Chlamydia trachomatis, the second most prevalent sexually transmitted infection. Glucose is a means via which gonorrhea invades mucus epithelial cells. Gonorrhea alters cellular proteins to facilitate more organism penetration. A localized inflammatory response brought on by the spread of gonorrhea results in the appearance of symptoms associated with a sexually transmitted infection.

In prior CDC 2015 guidelines, the recommended regimen for uncomplicated gonococcal infections of the cervix, urethra, pharynx, and rectum was ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose. However, per CDC’s new 2021 update, a single 500 mg IM dose of ceftriaxone is the new recommended regimen. For patients weighing ≥150 kg (300 lbs.), a higher dose is needed, and a single 1 gram IM dose of ceftriaxone should be administered. If ceftriaxone is not available, the alternative regimen is a single 240 mg IM dose of gentamicin According to the previous recommendations established by the Centers for Disease Control and Prevention (CDC) in 2015, the suggested treatment for uncomplicated gonococcal infections affecting the cervix, urethra, throat, and rectum consisted of a single intramuscular injection of ceftriaxone 250 mg, in addition to a single oral dosage of azithromycin 1 g.

According to the recent 2021 update from the Centers for Disease Control and Prevention (CDC), the recommended regimen has been revised to include a single intramuscular (IM) injection of ceftriaxone at a dosage of 500 mg. In the case of individuals with a body weight equal to or above 150 kg (300 lbs.), it is necessary to deliver a greater dosage. Specifically, a single intramuscular injection of 1 gram of ceftriaxone should be administered. In the event that ceftriaxone is unavailable, the recommended alternate treatment consists of either a single intramuscular dosage of gentamicin at 240 mg, combined with a single oral dose of azithromycin at 2 g, or a single oral dose of cefixime at 800 mg as monotherapy. In the event of a coinfection involving Chlamydia trachomatis, it is advised to include the prescribed treatment regimen of orally administered doxycycline at a dosage of 100 mg twice daily for a duration of 7 days into the existing treatment plan.

According to the Centers for Disease Control and Prevention (CDC, 2020), the administration of a single dosage of 1 g of azithromycin is advised for the treatment of chlamydia in pregnant individuals. Moreover, during the first years of the 1980s, professional consensus indicated that Chlamydia trachomatis was found to coexist with Neisseria gonorrhoeae in around 45 percent of those who were infected with the latter microorganism. According to a study conducted by Sadosvky (2004), the Centers for Disease Control and Prevention (CDC) have made a recommendation that patients who have been diagnosed with a gonorrhea infection should also receive treatment for Chlamydia. The study found that 20 percent of men and 42 percent of women who were infected with N. gonorrhoeae also tested positive for C. trachomatis.

One of the most often given antimicrobial medications is azithromycin, a broad-spectrum macrolide antibiotic (Sandman Z, Iqbal OA, 2023). It is an erythromycin derivative that covers a wide range of gram-positive organisms and has significantly increased effectiveness against gram-negative bacteria, including Enterobacteriaceae. Azithromycin works against many “atypical” bacteria, including chlamydiae (e.g., Chlamydia trachomatis and Chlamydophila psittaci), legionella (e.g., Legionella pneumophila), mycoplasma (e.g., Mycoplasma pneumoniae), and mycobacteria (e.g., Mycobacterium avium), because it inhibits bacterial protein synthesis rather than acting as a peptidoglycan cell-wall inhibitor like beta-lactam agents.

Azithromycin has superior tissue penetration and intracellular accumulation in its mode of action. Hepatic metabolism occurs, and biliary excretion predominates. When compared to other antimicrobials, azithromycin has a longer half-life and can be administered once daily, resulting in a shorter course of treatment. For example, treating a chlamydia infection requires administering 1 g of azithromycin instead of 100 mg of doxycycline twice a day for seven days. Patients with renal failure or illness may get azithromycin without consideration for their creatinine clearance level. Usually, no dosage change is required.

Similar to other macrolides, azithromycin side effects might result in QTc prolongation and have been linked to torsades de pointes and polymorphic ventricular tachycardia. Hepatotoxicity, which mostly consists of hepatic damage that occurs one to three weeks after starting treatment, is also seldom linked to azithromycin. Elevated transaminase levels and cholestatic jaundice are two clinical signs of hepatotoxicity. Similar to other macrolides, azithromycin often has gastrointestinal side effects including nausea and diarrhea. The intestinal motilin receptors are activated in a dose-dependent manner by all macrolides, hence promoting gastric motility. Because of this mechanism, erythromycin is often used by doctors to treat gastroparesis. Azithromycin-related life-threatening hypersensitivity responses, such anaphylaxis and Stevens-Johnson syndrome (SJS), are exceedingly rare. To a lower extent than other prevalent antibiotic classes (e.g., clindamycin, fluoroquinolones, and cephalosporins), macrolides also correlate with the development of Clostridium difficile infection (Sandman Z, Iqbal OA. 2023).

References:

Centers for Disease Control and Prevention (CDC). (2020).  Update to cdc’s treatment guidelines for Gonococcal Infection, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm. Published 2020.

Garcia MR, Leslie SW, Wray AA. (2023). Sexually Transmitted Infections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560808/

Mayor, M. T., Roett, M. A., & Uduhiri, K. A. (2012). Diagnosis and management of gonococcal infections. American family physician, 86(10), 931–938.

Sandman Z, Iqbal OA. (2023). Azithromycin. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK557766/#

Sadosvky, R. (2004). Co-treatment of chlamydia and gonorrhea infections. Am Fam Physician. 2004;69(4):961-962

Springer C., & Salen P. (2023). Gonorrhea.  In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558903/