What is the next step for a patient with hematuria and a history of gonorrhea, who was treated with ceftriaxone (a cephalosporin antibiotic) and azithromycin (an azalide antibiotic) a month ago and is now experiencing fatigue?

Evaluation and Management of Hematuria with Recent Gonorrhea Treatment

Immediate Next Steps

This patient requires urgent evaluation for treatment failure or reinfection with gonorrhea, along with comprehensive workup for the hematuria, which is not a typical symptom of uncomplicated gonorrhea. 1, 2

Test-of-Cure and Reinfection Assessment

• Obtain urethral culture for N. gonorrhoeae with antimicrobial susceptibility testing immediately, as persistent symptoms after treatment with recommended regimens suggest either treatment failure or reinfection 1, 2

• Collect specimens for nucleic acid amplification testing (NAAT) for both gonorrhea and chlamydia, though culture is preferred when treatment failure is suspected to allow susceptibility testing 3, 2

• Patients treated with ceftriaxone plus azithromycin do not routinely need test-of-cure unless symptoms persist, which is the case here 1, 2

• Infections detected after treatment with recommended regimens more commonly result from reinfection rather than treatment failure, indicating need for partner evaluation 1

Hematuria Workup

• Hematuria is NOT a typical manifestation of uncomplicated gonorrhea and requires separate evaluation for other causes including:

  • Urinary tract infection with gram-negative organisms (more common in men >35 years) 1
  • Urolithiasis
  • Glomerulonephritis
  • Malignancy
  • Trauma

• Obtain urinalysis with microscopy and urine culture for gram-negative bacteria 1

• Consider renal function testing and imaging if indicated by clinical presentation

Evaluation for Disseminated Gonococcal Infection

• Assess for signs of disseminated gonococcal infection (DGI), which can present with fatigue and systemic symptoms:

  • Examine joints for arthritis or tenosynovitis 4
  • Assess for dermatitis (pustular or hemorrhagic skin lesions) 4
  • Evaluate for clinical evidence of endocarditis and meningitis 4

• If DGI is suspected, hospitalization and parenteral ceftriaxone 1 g IV/IM every 24 hours is required 4

Treatment Failure Management Protocol

If gonorrhea is confirmed on repeat testing:

• Report the case to local public health officials within 24 hours 3, 2

• Consult an infectious disease specialist immediately 3, 2

• Consider salvage regimens for suspected treatment failure:

  • Gentamicin 240 mg IM plus azithromycin 2 g orally (single dose) - 100% cure rate in clinical trials 2, 5
  • Ertapenem 1 g IM for 3 days 2
  • Spectinomycin 2 g IM plus azithromycin 2 g orally (though spectinomycin has poor pharyngeal efficacy at only 52%) 2, 4

• Mandatory test-of-cure at 1 week after alternative treatment 3, 2

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days, as reinfection is the most common cause of persistent infection 1, 2

• Partners should receive dual therapy with ceftriaxone 250 mg IM plus azithromycin 1 g orally 2

• Patient must abstain from sexual intercourse until both patient and all partners complete therapy and are asymptomatic 1, 2

• If partners' treatment cannot be ensured, consider expedited partner therapy 3, 2

Concurrent STI Screening

• Repeat testing for syphilis, HIV, and hepatitis B at appropriate intervals (6,12, and 24 weeks if initial tests were negative) 1

• Screen for other STIs including chlamydia, as co-infection occurs in 40-50% of gonorrhea cases 2

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite historical effectiveness 2

• Do not assume hematuria is related to gonorrhea without ruling out other urologic causes 1

• Do not delay evaluation - persistent symptoms after appropriate treatment require immediate reassessment 1, 2

• Ensure antimicrobial susceptibility testing is performed on any positive cultures to guide further therapy 1, 2