Super Bug or poor technique?

[CSunday]

Thanks so much for the forum...it's an amazing resource and anxiety reliever. I am a 31 yr old hetero male currently living in Thailand. On 3/24 I went to a nearby hospital b/c I was suffering from a yellowish discharge from my penis, presumably related to an unprotected encounter with a sex worker. The on-call Dr had me produce a urine sample + a sample of the discharge fluid on a slide. The results came back positive for gon. The Dr wrote a prx which included 1 dose of ???? admin. by injection coupled with 7 days of doxycycline 2Xdaily (forgot the dosage) and 20 tablets of Metronidazole (which I opted not to take).



After the injection + doxycycline, everything appeared to return to normal.  On 4/26 I visited a different hospital b/c of some latent anxiety and had a # of tests run - HIV, gon., etc.  Everything came back negative. Whew!



Then on 5/20 I had another alcohol-inspired unprotected vaginal encounter with a sex worker -- very brief, I withdrew after maybe 30 sec to 1 min and sheathed the little guy with a jimmy-cap before completing the act.



On 5/24 I awoke and noticed I had a visible amount of discharge coming from my urethral opening.  I immediately went back to the original hospital for treatment and was seen by an "STD specialist".  This Dr. didn't have me undergo any tests (visual or clinical) and opted merely to quiz me on the discharge (color, amount) and whether there was any accompanying irritation during urination. I had another HIV test run -- clean again!



The "specialist" prx'd 3 doses of ???? admin. by injection 24hrs apart in conjunction with 7days of Ciprofloxacin (500mg 2x daily). My condition improved.  Before finishing the oral prescription, on 5/28, I had one protected encounter, contrary to what some on-line info recommends.  I had protected encounters again on the 3rd & 4th of June.  No problems.



Then on the 9th of June I was shocked to notice the familiar discharge along with painful urination. My ?'s are:



1.  What's going on?

2.  Is it possible that the 2nd treatment failed to eliminate a nasty "super bug" variety of Gon. that I contracted?  

3.  Is it possible the tests at the 2nd hospital were in error and the original infection recouped?

4.  My 3 protected encounters subsequent to seeking treatment were just that.  Protected.  I put the condom on prior to insertion and there was no "product failure" during intercourse.  Is it possible that during the condom removal I infected myself by carelessly allowing vaginal secretions (quite plentiful w/ encounter #1 - white and jelly-like) to come into contact with my urethral opening?

5.  Why do some sources recommend against sex or alcohol during the course of the antibiotics? What are the repercussions of having sex before verifying the original infection has been quashed?

6.  I'm going back to the original hospital immed. following this post but am concerned nonetheless.  Help! Considering my history, what would you prx for treatment?



Thx so much! Rock on!

[H. Hunter Handsfield, M.D.]

I cannot compete with the opinion of a provider who actually has examined someone, especially a provider who is knowledgeable about STDs.



1) As speculation, it sounds like you might have recurrent NGU, which is a fairly common problem. For quite a bit more detail, see my response in the thread "Recurrent Urethritis" just a couple of days ago.  It can be inconvenient, but is never serious.  If the doc you saw really is an STD specialist, he will be very familiar with this problem and might prescribe more prolonged antibiotic therapy.



Another possibility is trichomonas.  Your original provider undoubtedly prescribed metronidazole (Flagyl) for a reason.  Why didn't you take it?  Perhaps he even diagnosted trich; or perhaps he is aware that it's particularly common in men he sees with gonorrhea?  Or in sex workers in that area of town?



2) Some gonorrhea strains are relatively resistant to antibiotics, but almost never to the treatments you received (my bet is the injection was ceftriaxone, to which resistance is extremely rare or nonexistant).



3) You can be sure the original gonorrhea didn't pop up again.  But you could have been infected at the same time with bacteria that can cause NGU.



4) I cannot comment on your condom removal technique.  But most likely you were fully protected against new infections.



5) No sex is obvious--to avoid any risk of reinfection during treatment.  Avoiding alcohol probably is a myth, the legacy of old theories (50 years ago and more) that alcohol and spicy foods could cause NGU or interfere with antibiotics.  Today it is understood that you have to not get so drunk you forget to take your medications, but that's about it.



6) I never make a specific diagnosis or recommend treatment.  Those require professional evaluation in person.  Make sure your provider knows you didn't comply with the original treatment (metronidazole).



Good luck--  HHH, MD

[HHH,MD]

One more personal or moralistic comment on this forum, like the one you made to CSunday (which I deleted) will get you banned from any comments on any MedHelp forum.



HHH, MD

[CSunday]

Thank you for your advice Dr. H.  I appreciate your objectivity as well as your sensitivity to polemic posts by forum crusaders (let he who is without sin cast the first stone, eh?).



Anyhooz, I arrived at the hospital yesterday and managed to see a young but quite knowledgable doctor.  After asking quite a few detailed questions he requested a urinalysis and a Gramm? stain test.  After the results came back negative for gonorrhea, he concluded that most likely what I dealing with was a chlamydia infection that was not dealt with by the "specialist's" treatment regimine.  You were correct in assuming that I had been previously been treated with Ceftriaxone (saw my chart while there).  Is chlamydia immune to both Ceftriaxone as well as Ciprofloxacin?



So, I am currently on doxycycline (100mg 2xdaily) for a week and have my fingers crossed.  As for why I decided not to take the Flagyl, chalk it up to my own stupidity I guess.  I did mentioned my breach of prescribed treatment to the doctor.  Without making a statement directly contradicting the initial doctor (a huge cultural no-no here in Thailand, as the 1st doctor is his elder) he did indicate that he did not believe that medication was necessary.



Thanks again.