What further testing is needed for a patient with pneumonia who has improved with amoxiclav (amoxicillin-clavulanate) and has a history of recent sexual activity, presenting with cough, fever, shortness of breath (SOB), and sore throat, with a chest X-ray (CXR) showing pneumonia and no urinary symptoms?

Testing for Sexually Transmitted Infections in a Patient with Pneumonia Following Sexual Activity

For a patient with pneumonia who has improved with amoxicillin-clavulanate and has a history of recent sexual activity, pharyngeal and rectal testing for gonorrhea is strongly recommended in addition to the already completed urine testing, especially given the temporal relationship between sexual activity and respiratory symptoms.

Current Testing Status and Clinical Presentation

• Patient has already been tested for gonorrhea and chlamydia through urine, as well as HIV, syphilis, HBV, and HCV 1
• No testing for HSV was performed 1
• Patient presented with cough, fever, shortness of breath, and sore throat following sexual activity 1
• Chest X-ray showed pneumonia, which has improved with amoxicillin-clavulanate treatment 2, 3
• Patient denied urinary symptoms 1

Recommended Additional Testing

Pharyngeal and Rectal Testing for Gonorrhea

• Pharyngeal testing for gonorrhea is essential given the patient's sore throat and respiratory symptoms that began after sexual activity 1, 4
• Rectal testing for gonorrhea is indicated regardless of reported sexual practices to ensure comprehensive screening 4
• Acceptable specimen types include pharyngeal and rectal swabs, which may detect infections missed by urine testing alone 4

Pharyngeal and Rectal Testing for Chlamydia

• Pharyngeal and rectal specimens should also be tested for Chlamydia trachomatis 1, 4
• Chlamydial pneumonia can present with cough and respiratory symptoms, which aligns with this patient's presentation 1

Rationale for Additional Testing

• The temporal relationship between sexual activity and respiratory symptoms strongly suggests possible sexually transmitted respiratory infection 1
• Urine testing alone may miss extragenital infections, particularly in the pharynx which could explain the sore throat 4
• Pneumonia following sexual activity raises concern for sexually transmitted pathogens that can cause respiratory infections 1
• Improvement with amoxicillin-clavulanate does not rule out gonorrhea or chlamydia as contributing pathogens, as this antibiotic has activity against many respiratory pathogens 2, 3, 5

Testing Algorithm

1. Obtain pharyngeal swab for gonorrhea and chlamydia testing 1, 4
2. Obtain rectal swab for gonorrhea and chlamydia testing 1, 4
3. Consider C-reactive protein (CRP) measurement to monitor pneumonia resolution 1
4. No additional chest imaging is needed if symptoms have improved with treatment 1

Treatment Considerations

• If extragenital gonorrhea is detected, treatment should be with a single 500-mg dose of intramuscular ceftriaxone for people weighing less than 150 kg 4
• If chlamydia is detected, preferred treatment is doxycycline 100 mg orally twice daily for seven days 4
• Continue current pneumonia treatment with amoxicillin-clavulanate as it has shown effectiveness 2, 3, 5
• Testing for reinfection should be performed approximately three months after treatment 4

Common Pitfalls and Caveats

• Relying solely on urine testing for STIs may miss pharyngeal and rectal infections 4
• Assuming that improvement with antibiotics rules out sexually transmitted pathogens is incorrect, as amoxicillin-clavulanate has broad-spectrum activity 5, 6
• Failure to test all potential infection sites can lead to ongoing transmission and complications 1
• Not recognizing the temporal relationship between sexual activity and symptom onset can lead to missed diagnoses 1