What antibiotic treatment and testing are recommended for a female patient with a cutaneous infection in the genital area, presenting with purulent discharge and pain, and also requesting nicotine replacement therapy for smoking cessation?

Antibiotic Treatment and Testing for Genital Cutaneous Infection with Purulent Discharge

For a female patient with a cutaneous infection in the genital area presenting with pus and pain, empiric treatment should consist of ceftriaxone 125 mg IM plus doxycycline 100 mg orally twice daily for 7 days, with testing for gonorrhea and chlamydia before initiating therapy. 1

Immediate Diagnostic Testing Required

Before starting antibiotics, obtain the following specimens:

• Swab of the purulent discharge for Gram stain and culture for N. gonorrhoeae 1
• Nucleic acid amplification testing (NAAT) for both N. gonorrhoeae and C. trachomatis from the lesion or first-void urine 1
• Syphilis serology given the genital location and risk profile 1
• HIV counseling and testing should be offered 1

Empiric Antibiotic Regimen

The recommended treatment addresses the most common sexually transmitted pathogens causing genital infections with purulent discharge:

Primary Regimen:

• Ceftriaxone 125-250 mg IM as a single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1

This combination provides coverage against N. gonorrhoeae, C. trachomatis, and other common bacterial pathogens causing genital skin infections. 1

Alternative Regimen (if cephalosporin allergy):

• Spectinomycin 2 g IM single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1

Clinical Reasoning for This Approach

The genital location with purulent discharge raises concern for sexually transmitted infections, which are the most common cause of such presentations in sexually active women. 1 The CDC guidelines emphasize treating empirically for both gonorrhea and chlamydia when genital infections present with mucopurulent discharge, as coinfection rates are high and delayed treatment increases complications. 1

Critical distinction: While this appears to be a cutaneous infection, the genital location and purulent nature mandate coverage for STIs rather than treating it as simple skin flora (Staph/Strep). 1

Follow-Up Requirements

• Return in 3 days if no improvement to reassess diagnosis and consider alternative pathogens 1
• Test of cure is not required if symptoms resolve with recommended regimens 1
• Persistent symptoms after treatment completion warrant re-evaluation with repeat cultures and consideration of treatment failure versus reinfection 1

Partner Management

• All sexual partners within 60 days of symptom onset should be evaluated and treated with the same regimen 1
• Instruct patient to abstain from sexual intercourse until both she and her partner(s) complete therapy and are symptom-free 1

Common Pitfalls to Avoid

Do not treat this as simple cellulitis with cephalexin or dicloxacillin alone - the genital location with purulent discharge requires STI coverage regardless of appearance. 1

Do not use topical antibiotics alone - while mupirocin may be added for superficial skin involvement, systemic antibiotics are mandatory for genital infections with purulent discharge. 2

Do not delay treatment waiting for culture results - empiric therapy should begin immediately after specimens are collected. 1

Nicotine Replacement Therapy

For the requested 21 mg nicotine patches, this is appropriate for smoking cessation and can be prescribed concurrently with antibiotic therapy without drug interactions. The standard approach is 21 mg patches daily for 6 weeks, then taper to 14 mg for 2 weeks, then 7 mg for 2 weeks for patients smoking >10 cigarettes per day.

When to Escalate Care

Consider hospitalization or urgent consultation if:

• Fever or systemic symptoms develop 1
• Extensive cellulitis or signs of necrotizing infection (rare but life-threatening) 2
• No improvement within 72 hours of starting antibiotics 1
• Severe pain suggesting abscess formation 1