How to manage a patient with a sore throat and a history of Sexually Transmitted Infections (STIs)?

Management of Sore Throat in Patients with STI History

For patients presenting with sore throat and a history of STIs, empiric treatment for pharyngeal gonorrhea and chlamydia is recommended, with ceftriaxone 125 mg IM as a single dose plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days.

Assessment Approach

When evaluating a patient with sore throat and STI history, consider:

• Sexual practices (oral sex history specifically)
• Timing of last sexual contact
• Presence of other symptoms (discharge, genital lesions)
• HIV status
• Pregnancy status
• Drug allergies

Key Clinical Considerations

• Pharyngeal infections with N. gonorrhoeae or C. trachomatis can cause pharyngitis and tonsillitis but are completely asymptomatic in most cases 1
• Asymptomatic infections are an important reservoir for new infections 1
• Oropharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 2

Treatment Algorithm

First-Line Treatment:

1. Ceftriaxone 125 mg IM in a single dose 2, 3 PLUS
2. Either:
   • Azithromycin 1 g orally in a single dose (preferred for adherence concerns) 2, 3
   • OR
   • Doxycycline 100 mg orally twice daily for 7 days 2, 3

Alternative Regimens (for patients with allergies):

• Spectinomycin 2 g IM in a single dose (Note: only 52% effective against pharyngeal infections) 2
• Ciprofloxacin 500 mg orally in a single dose (if not contraindicated) 2

Special Populations:

Pregnant Patients:

• Ceftriaxone 125 mg IM in a single dose 2
• PLUS
• Azithromycin 1 g orally in a single dose or Amoxicillin 2, 3, 4
• Avoid quinolones and tetracyclines 2

Adolescents:

• Same as adult regimen if weight >45 kg 2
• Adjusted dosing for lower weights 3

HIV-Positive Patients:

• Same treatment regimen as HIV-negative patients 2

Follow-Up Recommendations

1. Test of Cure:

   • Not routinely needed for uncomplicated gonorrhea treated with recommended regimens 2
   • Exception: patients treated with spectinomycin for pharyngeal infection should have culture 3-5 days after treatment 2

2. Partner Management:

   • All sex partners from the previous 60 days should be evaluated and treated 2, 3
   • If last sexual contact was >60 days before symptoms/diagnosis, treat the most recent partner 2

3. Sexual Activity:

   • Patients should avoid sexual activity until therapy is completed and both they and their partners are asymptomatic 2

Important Clinical Pearls

• Pharyngeal infections require special attention as they are more difficult to eradicate than genital infections 2, 5
• Single-dose therapy with azithromycin improves compliance in patients who might otherwise not complete a multi-day regimen 6
• Persistent symptoms after treatment warrant culture for N. gonorrhoeae with antimicrobial susceptibility testing 2
• Treatment failures are usually due to reinfection rather than antimicrobial resistance, highlighting the importance of partner treatment 2
• Patients with STI history presenting with sore throat should always be evaluated for concurrent infections at other anatomical sites 7

Monitoring for Treatment Failure

• Persistent symptoms after treatment require re-evaluation
• Culture for N. gonorrhoeae with antimicrobial susceptibility testing
• Consider other causes of pharyngitis if gonorrhea and chlamydia tests are negative
• Consider retesting approximately 3 months after treatment due to high reinfection rates 3

By following this approach, clinicians can effectively manage patients with sore throat who have a history of STIs, reducing morbidity and preventing further transmission.