A 26-year-old female patient presents with 2 days of increasing midline lower abdominal/pelvic pain. She denies fever, vomiting, diarrhea, or abnormal vaginal discharge. She has some increased urinary urgency without dysuria. Her LMP was 3 weeks ago, and she has fairly regular cycles. She is sexually active and for the last 2 months has been monogamous. She takes oral contraceptive pills and does not use condoms. Over the past 6 months, she has had 3 different male sexual partners. She has never had an STI, but admits to 2 prior episodes of bacterial vaginosis.
On examination, normal vital signs are noted. There is mild suprapubic tenderness to palpation but no guarding or rebound. The pelvic exam shows some cervical erythema, but no overtly purulent cervical discharge. There is some cervical motion tenderness but no significant adnexal tenderness or mass. Endocervical swabs for gonorrhea and chlamydia are collected. The UA dip shows trace leukocytes but is otherwise negative. You are considering treating her as an outpatient for presumed PID, but her chart lists an allergy to penicillin. The patient was told that she had a diffuse rash while she was taking amoxicillin as a child. What is the preferred treatment plan?
a. Prescribe a 14-day course of levofloxacin 500 mg daily combined with metronidazole 500 mg BID; the patient cannot receive ceftriaxone due to her known penicillin allergy.
b. Prescribe doxycycline and metronidazole orally for 14 days and send the patient to the ED where she can receive the ceftriaxone dose under close observation in case anaphylaxis occurs.
c. Begin a 5-day course of nitrofurantoin for suspected UTI. Await culture results before beginning therapy for PID.
d. Administer ceftriaxone 500 mg IM once, then prescribe 14-day courses of doxycycline and metronidazole.
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Answer: D. There is no contraindication to ceftriaxone in a patient with a mild penicillin allergy, and the likelihood of treatment failure with other regimens is unacceptably high. The patient should be treated empirically, as a high percentage of PID cases are due to pathogens other than Neisseria gonorrhoeae or Chlamydia trachomatis. It is unnecessary to transfer this patient to the ED for medication administration and monitoring.
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