The Question
A 28-year-old man who has sex with men presents with 7 days of rectal pain, mucous discharge, and tenesmus after receptive anal intercourse with a new partner. He has no fever, denies urethral discharge, and reports intermittent adherence to condoms. Vitals: T 36.8°C, HR 78 bpm, BP 122/74 mmHg. On rectal exam there is mucopurulent discharge and mild erythema; anoscopy confirms mucosal inflammation. A rectal nucleic acid amplification test (NAAT) returns positive for Chlamydia trachomatis and negative for Neisseria gonorrhoeae; HIV fourth-generation test is negative. Which of the following is the most appropriate treatment?
See the answer and explanation below:
Post-Call Recovery Reads
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A
Explanation
High-Yield Pearl: Doxycycline 100 mg twice daily for 7 days is the preferred first-line therapy for uncomplicated rectal, urethral, and cervical Chlamydia trachomatis infections; single-dose azithromycin is no longer preferred for rectal infections because of higher treatment failure rates.
Detailed Reasoning: Current CDC STD Treatment Guidelines recommend doxycycline 100 mg PO twice daily for 7 days as first-line therapy for chlamydial infections of the rectum, urethra, and cervix due to superior efficacy compared with single-dose azithromycin, particularly for rectal infection. Azithromycin 1 g single dose (Option B) has been associated with higher microbiologic failure in rectal chlamydia and is generally reserved when adherence to a multi-day regimen is unlikely. Ceftriaxone (Option C) is the recommended treatment for gonorrhea but has no reliable activity against intracellular Chlamydia and would be insufficient alone for a positive chlamydial NAAT. A 2 g single dose of azithromycin (Option D) is not recommended routinely because of frequent GI adverse effects and lack of evidence for superior efficacy, and metronidazole (Option E) treats anaerobes and Trichomonas, not chlamydia. Management should also include partner notification/treatment, testing for other STIs including HIV and syphilis, counseling on condom use, and repeat testing at approximately 3 months for reinfection surveillance; test-of-cure is reserved for pregnancy or persistent symptoms per CDC guidance.
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