Treatment Failure

[Tbzz34]

Dear Dr Handsfield,

Thank you for an amazing service.

On 4th September I had unprotected sex with Person A (new partner).  I was unsure of the status of this person; I took 1g of Azithromycin (4 x 250mg) on the following day, 5th September.  On the 7th September I took a further 1g of Azithromycin combined with Cefixime (2 x 200mg).  I waited the recommended 7 days, plus another 3 for peace of mind.  After treatment, I noticed a single occasion of discharge (clear, sticky, like seamen), which was very small, which I had to squeeze to see.  I beleived this was natural and I was clear.  I then had unprotected sex with Person B on 18th (clear status).

Stupidly, I again had unprotected sex with Person A (16th October) – I took 1g of Azithromycin combined with Cefixime 3 days later on the 18th of October.  One week after (25th October) I noticed a few symptoms–slight discharge (once or twice) and dull pain in my testis.  

I visited my clinic (in the UK) - the doctor took a swab finding “puss cells” under the microscope – she said it could be possible that these are dead infection cells which are still clearing after the second exposure and treatment (she said if they were anything they looked like Chlamydia, not Gon).  She gave me a further 1g Azithromycin.  

Can you please answer my questions.

1.When I initially took the antibiotics (1-2 days after exposure) was this too early?

2.Taking into consideration all of the events, is there a possibility of treatment failure at any stage?  Is it possible that my body could have built up a resistance to Azithromycin? I have taken this quite alot.

3.After completing the treatment is Person B at risk?

4.Do you agree that the presence of puss cells will be a result of dead cells clearing out after treatment? How long do “puss cells” hang stay after treatment ?

5.I am confused why symptoms are occuring now, a week after treatment?

Thanks for taking the time to read this post.

[Edward W Hook, MD]

First, as I siad before, WBCs may not be indicative of STD and if your STD tests are negative, you should seek other explanations.  On the other hand, if the STD tests are positve, both treatment failures and false positves are quite rare but both have been known to occur.  If your test is positve and your partners do not have positve tests, then, in this situation, false positves are more likely but the entire situation needs careful evaluation.  Let's see what your tests show and not get too far ahead of things.  EWH

[Tbzz34]

Thanks again for the above - I guess this is just a case of waiting for the results. I have completed the treatment given by the GUM clinic. I have one final question which will help me cope with the wait.

I'm still pretty concerned by the "puss cells" found as discussed above. As far as I can see it, the results could go the following ways:

1. Negative - end of story, lesson learned. The puss cells were a result of something else.

However, I'm a bit unsure of the other scenarios. If the result is positive, could this be explained by 2. A false positive, where the treatment has killed anything off, and the test is picking up the dead cells? 3. A valid positive and the treatment hasn't worked?

The thing that concerns me the most is how to interpret a positive test after all the above treatment measures ie is there any way of telling if it is a false positive or a legitimate positive and what I have taken hasn't worked?

Thank you for taking my last question.

[Edward W Hook, MD]

1.  Azithromycin resistance has been reported, both for gonorrhea and for chlamydia but in both cases it is extraordinarily rare. It is not the body that become resistant but the organisims.  Your testing will tell if the organisims are still present.

2 and 3.  It would be unusual for STD-related white blood cells ("pus cells") to be present at 10, or even 7 days after successful therapy.  If the tests are negative for STDs, your doctor should be looking for other causes of the WBCs.  The list of possiblity is far too long to go through here and sorting things out should be accomplished in the context of a complete history and physical- something that cannot be done  on line.  EWH

[Tbzz34]

Dr Hook, thank you for a prompt and detailed answer - it has put my mind to rest. I was wondering if I could ask you one or two follow up questions to your comments above.

1.Have you ever come across azithromycin resistance? My worry is that my body is resistant to the medication.

2.The guidance here is you wait for 7 days, where I waited 10. The "dead puss cells" that may br floating around, can these be infectious? Or is it the case that after 7 days you can no longer pass infection on?

3.Im finding it hard to understand the presence of puss cells in the swab, what can be the non std causes of such an issue? Also, when the test results come in three weeks, if there has been an infection, will this show up as positive even though I have taken the antibiotics?

Thanks again!

[Edward W Hook, MD]

Welcome to the Forum.  I'll be answering your question.  FYI, Dr. Handsfield and I share the forum and which of us answers a question depends on the day and our schedules.  Today you got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

Your post is an interesting one and a great lesson for other clients as to why self medication in the absence of tests is a mistake which all too often just confuses issues.  Let's examine the situation:
- You assume that partner A is infected but have no basis for that assumption.
-Further, the fact is that even if partner A was infected, most exposures to infected partners do not lead to transmission, thus there really is little chance that you were infected.
-Even if you were, following each exposure you took medications which would be curative for over 97% of gonorrhea, chlamydia and NGU infections and thus have nothing to worry about..

Acknowledging all of these to be the case, let's now work through your questions:

1.When I initially took the antibiotics (1-2 days after exposure) was this too early?
No, Infections are easier to prevent than to cure.  If anything, the timing of the antibiotics you took make infection less likely, not more likely.  

2.Taking into consideration all of the events, is there a possibility of treatment failure at any stage?  Is it possible that my body could have built up a resistance to Azithromycin? I have taken this quite alot.
There is little reason to worry about failures.  In studies treatment failures occur 2-3% of the time and in your case, you do not even know that you were infected.

3.After completing the treatment is Person B at risk?
If you were infected with something, person B would be at about a 30-40% chance of becoming infected, HOWEVER, you do not know that you were infected.  if your tests are negative, person B is not at risk.  

4.Do you agree that the presence of puss cells will be a result of dead cells clearing out after treatment? How long do “puss cells” hang stay after treatment ?
Inflammation can be present for several days following successful treatment. Inflammatory cells can also arise from the irritation of repeated vigorous self-examination in persons who are not infected.  If the gonorrhea and chlamydial tests are negative, I would not worry.  

5.I am confused why symptoms are occuring now, a week after treatment?
The symptoms you describe are non-specific and I would not worry about them until test results are available.  the discharge you note may well be normal discharge which is present but unnoticed an most men. The testicular discomfort is non-specific as well.

Bottom line, your use of antibiotics without testing would have likely taken care of any STD present but has certainly confused the issue. At this time, my suggestion is to stop repeatedly examining yourself, to not worry and to wait for the test results.  EWH