Recommended Antibiotic Regimens for Urethritis Treatment
For nongonococcal urethritis, the first-line treatment is azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days. 1, 2
Initial Treatment for Urethritis
First-Line Regimens for Nongonococcal Urethritis (NGU)
- Azithromycin 1 g orally in a single dose 1, 2, 3
- OR Doxycycline 100 mg orally twice daily for 7 days 1, 2, 4
Alternative Regimens for NGU
- Erythromycin base 500 mg orally four times daily for 7 days 1
- OR Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1
- OR Levofloxacin 500 mg orally once daily for 7 days 1, 2
- OR Ofloxacin 300 mg orally twice daily for 7 days 1
For Gonococcal Urethritis
- Ceftriaxone 125-250 mg IM in a single dose 1, 2
- PLUS either Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice daily for 7 days 2, 5
Treatment Selection Considerations
Advantages of Azithromycin
- Single-dose therapy improves compliance 6, 7
- High microbiological cure rates (83-100%) for chlamydial infections 7, 8
- Directly observed therapy possible 1
- Well-tolerated with mild, self-limited adverse events in about 9% of patients 8
Advantages of Doxycycline
- Lower cost compared to azithromycin 5
- Comparable clinical cure rates to azithromycin (77% vs 81%) 7
- Effective against tetracycline-susceptible Ureaplasma species 9
Management of Persistent or Recurrent Urethritis
Diagnostic Criteria for Retreatment
- Objective signs of urethritis must be present (discharge or ≥5 polymorphonuclear leukocytes per high-power field) 1, 9
- Symptoms alone without objective signs are not sufficient for retreatment 1, 9
Recommended Regimen for Persistent/Recurrent Urethritis
- Metronidazole 2 g orally in a single dose 1, 9
- OR Tinidazole 2 g orally in a single dose 1, 9
- PLUS Azithromycin 1 g orally in a single dose (if not used for initial episode) 1, 9
Partner Management
- Refer all sexual partners within the preceding 60 days for evaluation and treatment 1, 9
- Partners should receive the same treatment regimen as the index patient 9
- Both patient and partners should abstain from sexual intercourse until 7 days after therapy is initiated and symptoms have resolved 1, 9
Follow-Up Recommendations
- Patients should return for evaluation if symptoms persist or recur after completion of therapy 1, 9
- Persistence of symptoms beyond 3 months should prompt evaluation for chronic prostatitis/chronic pelvic pain syndrome 1, 9
Common Pitfalls to Avoid
- Treating based on symptoms alone without confirming objective signs of urethritis 9
- Failing to address possible reinfection from untreated partners 9
- Using fluoroquinolones in areas with high resistance rates 1, 2
- Using oral penicillin, which is ineffective for gonococcal infections 1, 2
- Using azithromycin 1 g alone for gonorrhea treatment, which is insufficient 2