From the Guidelines
The most appropriate therapy for this patient is a single intramuscular dose of ceftriaxone 500 mg plus oral azithromycin 1 gram as a single dose. This patient has gonorrhea, as evidenced by her symptoms of dysuria and purulent discharge, along with the finding of gram-negative intracellular diplococci on Gram stain, which is consistent with the diagnosis of gonorrhea as described in the guidelines by the U.S. Centers for Disease Control and Prevention 1. The dual therapy approach is recommended because of increasing antibiotic resistance in Neisseria gonorrhoeae and to cover for possible co-infection with Chlamydia trachomatis, which occurs in up to 50% of patients with gonorrhea. Some key points to consider in the management of this patient include:
- The importance of treating both gonorrhea and potential chlamydial co-infection, as both can cause significant morbidity if left untreated, including pelvic inflammatory disease and its sequelae 1.
- The need for the patient to abstain from sexual activity for 7 days after completing therapy to prevent transmission to partners.
- The recommendation for testing for other sexually transmitted infections, including HIV, syphilis, and hepatitis B and C, given the patient's presentation with a sexually transmitted infection.
- The guidance that a test of cure is not routinely recommended for uncomplicated gonorrhea treated with the recommended regimen, but the patient should be advised to return if symptoms persist or recur, as suggested by the CDC guidelines 1.
From the FDA Drug Label
Uncomplicated Gonorrhea (cervical/urethral and rectal) caused by Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase-producing strains of Neisseria gonorrhoeae. The most appropriate therapy for this patient is ceftriaxone (IM), as the Gram stain reveals gram-negative intracellular Diplococci, which is consistent with Neisseria gonorrhoeae, and the patient's symptoms are consistent with uncomplicated gonorrhea.
- The patient's symptoms include dysuria, foul-smelling discharge, and a pelvic exam showing inflammation of the Bartholin glands, erythema of the vaginal vault, and purulent discharge from the urethra.
- The FDA drug label for ceftriaxone indicates that it is effective against Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains 2.
- It is essential to note that ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis, so appropriate antichlamydial coverage should be added if Chlamydia trachomatis is one of the suspected pathogens 2.
From the Research
Diagnosis and Treatment
The patient's symptoms, including dysuria, foul-smelling discharge, and inflammation of the Bartholin glands, erythema of the vaginal vault, and purulent discharge from the urethra, along with the Gram stain revealing gram-negative intracellular Diplococci, are indicative of a gonococcal infection 3, 4.
Recommended Treatment
The recommended treatment for uncomplicated gonococcal infections is a single 500 mg intramuscular dose of ceftriaxone 3. If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 3.
Alternative Treatment Options
Alternative treatment options, such as a single 800 mg oral dose of cefixime plus doxycycline, may be considered in certain cases, such as patients with ceftriaxone allergy or in settings where ceftriaxone is unavailable 5.
Importance of Antimicrobial Stewardship
It is essential to continue monitoring for the emergence of ceftriaxone resistance through surveillance and healthcare providers' reporting of treatment failures to ensure the continued efficacy of recommended regimens 3, 6.