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PH8.4 | PH8.4 | Syndromic Antibacterial Treatment Plans — SDL Guide — SDL Guide (Part 3)

Self-Assessment: Syndromic Prescribing

Scenario A: A 35-year-old woman with recurrent UTI (5 episodes in the past year) has been treated repeatedly with ciprofloxacin by her GP. Urine cultures consistently grow E. coli. This time, the E. coli is resistant to ciprofloxacin, TMP-SMX, and amoxicillin but sensitive to nitrofurantoin, fosfomycin, and meropenem. She has a normal eGFR (80 mL/min), is not pregnant, and has a normal renal ultrasound. What do you prescribe now, and what is your long-term management plan?

Discussion: For the current acute episode (lower UTI): nitrofurantoin 100mg MR BD × 5 days (sensitive, appropriate for cystitis, normal eGFR). Fosfomycin 3g single dose is an equally valid option. Do NOT use meropenem for uncomplicated UTI regardless of sensitivity (last-resort agent). For long-term recurrence prevention: consider low-dose nitrofurantoin 50mg nocte × 6–12 months OR post-coital prophylaxis; review for hormonal vaginal oestrogen (if post-menopausal); counsel on voiding habits, hydration, perineal hygiene. The current antibiogram showing ciprofloxacin resistance is a signal to stop empiric fluoroquinolone use for this patient permanently.

Scenario B: A 30-year-old man presents with penile ulcer (painless), non-tender inguinal lymphadenopathy bilaterally. He had unprotected sex with a commercial sex worker 4 weeks ago. VDRL: reactive, titre 1:16. TPHA positive. What is your diagnosis, treatment, and what counselling will you provide?

Discussion: Primary syphilis (painless genital chancre + reactive VDRL/TPHA = serological confirmation of primary or secondary syphilis). Treatment: benzathine penicillin G 2.4 million units IM single dose. Warn about Jarisch-Herxheimer reaction (fever, myalgia, headache within 2–8 hours — take paracetamol, not an allergy, do not stop treatment). Counsel: all sexual contacts from the past 3 months must be tested and treated presumptively. HIV testing strongly recommended (concurrent HIV infection modifies syphilis management — higher doses, longer courses, LP to exclude neurosyphilis in some cases). VDRL titre should fall ≥4-fold by 3 months (test of cure — confirms response); if titre fails to fall, consider neurosyphilis or re-infection.

Scenario C: You are counselling a young woman who has just been diagnosed with chlamydia and given azithromycin 1g today. She says, 'My boyfriend says he is fine, he has no symptoms. Does he need to take medicine?' How do you respond?

Discussion: Emphatically yes. C. trachomatis is asymptomatic in 50–70% of infected men but is still transmissible. If her partner is not treated, he remains infected and will reinfect her — treatment failure will be blamed on antibiotic resistance when it is actually reinfection from an untreated contact. Her partner should receive azithromycin 1g today (or doxycycline 100mg BD × 7 days). Both should abstain from sexual intercourse for 7 days after the last dose of treatment and until all partners are treated.