Empiric Treatment for Male STIs
For symptomatic males with suspected sexually transmitted infections, treat empirically with dual therapy covering both gonorrhea and chlamydia: ceftriaxone 500 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1
When to Treat Empirically
Empiric treatment is indicated for males with urethritis when:
- Mucopurulent or purulent urethral discharge is present 2
- Gram stain shows ≥5 WBCs per oil immersion field 2
- First-void urine microscopy demonstrates ≥10 WBCs per high-power field 2
- Positive leukocyte esterase test on first-void urine 2
If none of these criteria are present, empiric treatment is still recommended for men at high risk who are unlikely to return for follow-up evaluation. 2 This recognizes the reality of clinical practice where loss to follow-up is common and untreated infections lead to ongoing transmission and complications.
Recommended Empiric Regimen
Primary Recommendation
This updated 2020 CDC recommendation increases ceftriaxone from the previous 250 mg dose to 500 mg due to evolving resistance patterns, while maintaining doxycycline for chlamydia coverage when coinfection has not been excluded. 1
Alternative Single-Dose Option (When Compliance is Uncertain)
Azithromycin offers the advantage of directly observed single-dose therapy, maximizing compliance, but is more expensive and causes more gastrointestinal side effects (35% of patients, with 10% moderate and 3% severe). 3 The single-dose azithromycin option is particularly valuable when you cannot ensure the patient will complete a 7-day doxycycline course. 2
Rationale for Dual Therapy
Dual therapy is essential because:
- Chlamydia coinfection occurs in a substantial proportion of gonorrhea cases 4
- Testing delays mean you cannot wait for results before treating 2
- Untreated chlamydia leads to complications including epididymitis, urethral stricture, and facilitates HIV transmission 2
- Reinfection from untreated partners is the primary cause of treatment failure 4
Special Considerations for Mycoplasma genitalium
If persistent or recurrent urethritis occurs after standard treatment, test for M. genitalium using NAAT with macrolide resistance testing when available. 5 For suspected M. genitalium:
- Azithromycin is preferred over doxycycline (85-95% cure rate vs 30-40%) 5
- Moxifloxacin 400 mg daily for 7 days is recommended for macrolide-resistant infections 5
Critical Management Steps
Instruct patients to:
- Abstain from sexual intercourse for 7 days after initiating therapy and until symptoms resolve 2
- Abstain until all sex partners are treated to prevent reinfection 2
- Return for evaluation if symptoms persist or recur after completing therapy 2
All sexual partners within the preceding 60 days must be evaluated and treated empirically for both gonorrhea and chlamydia, regardless of symptoms or test results. 4 If the last sexual contact was >60 days before diagnosis, treat the most recent partner. 4
Additional Testing
All patients diagnosed with an STI should receive:
This addresses the reality that STIs cluster and patients with one infection are at higher risk for others.
Common Pitfalls to Avoid
Do not:
- Treat based on symptoms alone without objective evidence of urethritis - this leads to overtreatment and antimicrobial resistance 2
- Use quinolones (ciprofloxacin, ofloxacin, levofloxacin) for gonorrhea - resistance is now widespread and these are no longer recommended 2, 1
- Delay treatment waiting for test results - empiric therapy should be initiated immediately when clinical criteria are met 2
- Forget to treat partners - this is the most common cause of reinfection and treatment failure 4
Medications should be dispensed on-site in the clinic when possible, with the first dose directly observed to maximize compliance. 2