Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A 22-year-old woman presents for follow-up after a recent clinic visit where she requested STI screening, sexually transmitted infection screening, and tested positive for Chlamydia trachomatis. She states, “I'm really surprised. I feel fine.” Her current medications include a combined oral contraceptive, and her LMP was about ten days ago with appropriate timing and a three day light flow. The NP considers which of the following is the best option:
A. Given she is asymptomatic, no further intervention is needed.
B. Oral azithromycin as a single dose should be offered today.
C. Testing for Chlamydia trachomatis should be repeated today.
D. 7 day course of oral doxycycline is advised.
The correct answer is D. A 7 day course of oral doxycycline is advised.
Where should you start? First, establish what type of question this is. Given we’re advised that she recently had an abnormal lab test, and what's the next best option, this is of course, a plan/intervention question.
Let's take a look at some background information. Chlamydia infection is the most commonly reported STI affecting primarily adolescents and younger adults under the age of 25 years. When symptomatic and female birth assignment, mucopurulent vaginal discharge, dysuria, dyspareunia, and post-coital bleeding are often reported. At the same time, please remember up to 90% of women with Chlamydia are without symptoms. And I will tell you, my many decades of practicing and doing a lot of work with people who have or are at risk for STI, I back that up. I cannot tell you how many times I've had a patient, regardless of birth gender assignment, tested positive for Chlamydia and have zero symptoms. Up to 15% of women with Chlamydia will progress to develop pelvic inflammatory disease. And with PID, the uterus, the fallopian tubes, and the adjacent structures are involved. Due to post-infection tubal scarring, what can happen with PID from Chlamydia trachomatis is infertility. In other words, a type of infertility caused by the tubes being scarred and therefore the egg being produced but unable to meet sperm in the fallopian tube due to the scarring.
Routine screening, that is testing that is encouraged and offered to all in a given group, even in the absence of symptoms, screening for C. trachomatis infection is recommended annually for all sexually active females aged 25 years and younger, as well as older women who are at higher risk for infection. Increased risk includes having a new sexual partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner with an STI.
Routine screening, again, remember the use of the word routine screening, when used appropriately, meaning it means all people in a group who do not have symptoms. Routine screening for all males is not currently recommended. For all those individuals at higher risk, such as outlined above, testing is recommended. Obviously, symptomatic individuals should be tested. But this woman came in asking for the screening, as we were told in the question, and then says, “Wow, I’m really surprised it came out positive, I feel fine.” Select antimicrobial therapy, when taken as advised, is highly effective at eradicating this infection, whether a person has symptoms or not.
So, this question offers a few challenges. We’ve had intervention questions before, but they were generally like, here’s the problem, here are four things to treat it with. Which one is the best? But this question actually gives us two antimicrobial options plus two testing options. Let's take a few minutes and break this down.
One more time:
A 22-year-old woman presents for follow-up after a recent clinic visit where she requested STI screening. She tested positive for Chlamydia trachomatis. She states, “I'm really surprised. I feel fine.” Her current medications include a combined oral contraceptive and her LMP was about ten days ago with appropriate timing and a three day light flow. The NP considers which of the following is the best option:
A. Given that she's asymptomatic, no further intervention is needed. Well, of course this is incorrect. As was mentioned, likely the majority of women with chlamydia are without symptoms, but remain at significant risk for pelvic inflammatory disease with the long term risk of tubal scarring and subsequent difficulty with conceiving, as well as higher risk for ectopic pregnancy. To boot, women with PID can get very sick, and therefore of course she would require treatment, whether symptomatic or not.
Option B. Oral azithromycin as a single dose should be offered. Well, this is where things get a little more complicated. If in your NP studies, you were in school, particularly prior to the summer of 2021, you might have been told that azithromycin as a single dose was a first-line therapy for the treatment of Chlamydia trachomatis uncomplicated infection in all regardless of birth gender assignment. But now, with the current guidelines, which were promulgated summer 2021, this answer is now incorrect. So earlier versions of STI guidelines did advocate for a single dose of azithromycin as a first-line drug. I will tell you in my darker moments in practice, I pined for the good old days when all you had to do was treat Chlamydia with a single dose of azithromycin. Easy enough to do. However, the current STI guidelines and the guidelines that will be on your boards, do not advocate for this drug as a first-line therapy due to increasing rates of antimicrobial resistance. In one scenario, during pregnancy, azithromycin is the first-line therapy. Here we are advised that she’s on combined oral contraceptives recently had appropriately timed menses. This is very reassuring that she's not pregnant, and therefore we can go ahead and treat her with the recommended medication. Don't go ahead and fall for this, well, she's a woman of reproductive age, so I'm going to assume she's pregnant. That's incorrect. In a scenario like this, you can walk away and say, I'm really reassured she's not pregnant.
Option C. Testing for Chlamydia trachomatis should be repeated today. Again, this is not correct. The preferred diagnostic testing for C. trachomatis infection is the NAAT or N-A-A-T, or nucleic acid amplification test. This test can be used at site of symptomatic infection or in the urine sample, and the latter is most commonly used for asymptomatic screening. And it's wonderful. Great sensitivity on it, really, really, really helpful, because all you're asking the person to do is pee in a cup. The currently available NAAT testing is highly sensitive and retesting, even in the absence of symptoms is not required. General rule: Given the many advances in laboratory testing, repeating a test will not be the correct answer on boards because it's not the correct answer in practice. If you're thinking yeah, but in the inpatient setting we repeat tests all the time. Yes, you're in the inpatient setting. You're in the emergency department. Patients are quite unstable and they're having their tests repeated frequently, not due to lab error, in this case, it would be a false positive, not due to the lab error, but more due to given issues of their physiologic instability.
Option D. A 7 day course of oral doxycyline is advised.
This is the correct answer and is consistent with current practice. Doxycyline provides more robust coverage against C. trachomatis, it is the CDC’s first-line recommendation in this scenario, particularly in the absence of pregnancy.
Key takeaway knowledge of when to proceed to treat certain infections, even when the patient is asymptomatic, and which patient and disease-specific antimicrobial to use, is key to NP board and clinical practice success.
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