What is the empiric treatment for sexually transmitted urethritis?

Empiric Treatment for Sexually Transmitted Urethritis

The first-line empiric treatment for sexually transmitted urethritis is azithromycin 1g orally in a single dose OR doxycycline 100mg orally twice daily for 7 days. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis of urethritis with at least one of the following:

• Mucopurulent urethral discharge
• Gram stain of urethral secretions showing ≥2 WBCs per oil immersion field
• First-void urine with ≥10 WBCs per high-power field
• Positive leukocyte esterase test on first-void urine 1

Treatment Regimens

First-Line Regimens

• Azithromycin 1g orally in a single dose 2, 1, 3
  • Advantages: Single-dose therapy, improved compliance, directly observed therapy
  • FDA-approved for urethritis due to Chlamydia trachomatis or Neisseria gonorrhoeae 3

OR

• Doxycycline 100mg orally twice daily for 7 days 2, 1, 4
  • FDA-approved for nongonococcal urethritis (NGU) caused by C. trachomatis or U. urealyticum 4

Alternative Regimens (if first-line treatments are contraindicated)

• Erythromycin base 500mg orally four times daily for 7 days
• Erythromycin ethylsuccinate 800mg orally four times daily for 7 days
• Ofloxacin 300mg orally twice daily for 7 days
• Levofloxacin 500mg orally once daily for 7 days 2

Management of Persistent or Recurrent Urethritis

If symptoms persist after initial treatment:

1. Confirm objective signs of urethritis
2. Rule out reinfection or non-compliance
3. Consider testing for Trichomonas vaginalis and tetracycline-resistant Ureaplasma urealyticum 2, 1

Recommended regimen for persistent urethritis:

• Metronidazole 2g orally in a single dose PLUS
• Azithromycin 1g orally in a single dose (if not used for initial episode) 2, 1

Patient Instructions and Follow-Up

• Patients should abstain from sexual intercourse until 7 days after therapy is initiated, provided their symptoms have resolved 2
• Sexual partners within the preceding 60 days should be referred for evaluation and treatment 2, 1
• Patients should return for evaluation if symptoms persist or recur after completing therapy 2
• Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not sufficient basis for re-treatment 2

Special Considerations

HIV Infection

• HIV-infected patients should receive the same treatment regimens as HIV-negative patients 2

Clinical Efficacy

• Research has shown that single-dose azithromycin is as effective as a standard 7-day course of doxycycline in achieving clinical cure for NGU, with comparable clinical cure rates regardless of the presence or absence of Chlamydia or Ureaplasma infection 5

Common Pitfalls to Avoid

1. Treating without confirming diagnosis: Ensure objective signs of urethritis are present before initiating antimicrobial therapy 2

2. Inadequate partner management: All sexual partners within the preceding 60 days should be evaluated and treated 1

3. Premature re-treatment: Symptoms alone without objective signs of inflammation are not sufficient for re-treatment 2

4. Neglecting to test for other STIs: Patients diagnosed with urethritis should receive testing for other STIs, including syphilis and HIV 2

5. Inadequate follow-up: Persistence of symptoms beyond 3 months should alert the clinician to the possibility of chronic prostatitis/chronic pelvic pain syndrome in men 2