I consider this one of the most influential articles ever for this blog because it will change your urgent care practice. The link mentions a semi-new and virulent urethritis pathogen- Mycoplasma genitalium. Long lumped under the amorphous microbiological class of "atypical pathogens for urethritis", this mycoplasma strain in recent studies has been implicated for 15-20 % of clinically significant urethritis issues. Moreover, this mycoplasma displays considerable resistance to the usual urethritis empiric meds of doxycycline, cipro, and zithromax. In fact, it currently (unless resistance patterns morph over time) is mainly susceptible to Avelox.
Just think, how many times has a male (or female) come in with urethritis, you see some WBC on the UA, you empirically start zithromax or doxycycline, and then they still have significant symptoms 5 days later when he or she returns to the clinic and you say, "Well, good news is your gonorrhea and chlamydia are negative. I am unsure why you still have urinary issues (you internally think non compliance)." Perhaps you send them to a urology consult, expecting interstitial cystitis. Regardless, this article outlines that persistent urethritis (or even cervicitis) issues unresponsive to the usual antibiotics with a negative gc/chlamydia need a course of Avelox (to eradicate M. genitalium), and also a course of concomitant Flagyl, to eradicate the less common Ureaplasma urealyticum.
SUMMARY: Don't shrug your arms with urethritis when the patient returns with issues despite treatment. Instead, try a 7-10 day course of Avelox and Flagyl, The article estimates 15-20% of urethritis is due to these non culturable organisms. Hence, this means the urine culture also will show up negative. Note also with M. genitalium that there seems to be resistance to traditional fluoroquinolones like Cipro or Levaquin. While Avelox and Flagyl should NOT be first line treatments, they certainly should be second line urethritis interventions. I can say this will give me new options for many of my frustrated patients, and I am sure you too have patients like this....if you just keep your eyes open.....
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