What is the recommended treatment for urethritis caused by gonorrhea?

Treatment of Gonococcal Urethritis

For uncomplicated gonococcal urethritis, treat with ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 7 days to cover possible chlamydial coinfection. 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the current standard of care for gonococcal urethritis, representing an update from the previous 250 mg dose due to antimicrobial stewardship concerns and evolving resistance patterns 1

• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded, as approximately 20-50% of patients with gonorrhea have concurrent chlamydial coinfection 1, 2

• The shift away from dual therapy with azithromycin occurred due to increasing azithromycin resistance and concerns about antimicrobial stewardship, while ceftriaxone resistance remains low 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally as a single dose can be used for uncomplicated cervical/urethral gonococcal infections, though it is less effective than ceftriaxone 3, 4

• Cefixime should NOT be used for pharyngeal gonorrhea as oral cephalosporins have unacceptably low cure rates (approximately 57%) for pharyngeal infections 4

• Fluoroquinolones (ciprofloxacin 500 mg or ofloxacin 400 mg) are no longer recommended in most settings due to widespread resistance, particularly in men who have sex with men, patients with recent foreign travel, and infections acquired in areas with high quinolone-resistant N. gonorrhoeae prevalence 4

Critical Management Points

• Always test for both gonorrhea and chlamydia before initiating treatment, as specific diagnosis improves partner notification and compliance 5, 4

• Objective documentation of urethritis should include at least one of: mucopurulent discharge on examination, ≥10 white blood cells per high-power field in first-void urine, positive leukocyte esterase test, or ≥2 white blood cells per oil immersion field on Gram stain 5

• Patients must abstain from sexual intercourse for 7 days after treatment initiation and until symptoms resolve and partners are adequately treated 5, 6

Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated with the same regimen as the index patient, regardless of symptoms or test results 4, 5, 6

• If the last sexual contact was more than 60 days before symptom onset, treat the most recent sexual partner 4

• Expedited partner therapy (providing prescriptions or medications directly to patients for their partners) is an acceptable option when partner treatment cannot otherwise be ensured 4

Follow-Up and Persistent Symptoms

• Routine test-of-cure is NOT recommended for patients treated with recommended regimens who become asymptomatic 4, 5

• However, retesting at 3 months is recommended due to high reinfection rates (not treatment failure), which occur in the majority of patients within several months 4

• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing and consider alternative diagnoses including C. trachomatis, Trichomonas vaginalis, or tetracycline-resistant Ureaplasma urealyticum 4, 6

Treatment of Persistent Urethritis After Initial Therapy

• First confirm objective signs of urethritis are still present before retreating, as symptoms alone without laboratory evidence do not warrant additional antimicrobials 6, 4

• Rule out non-compliance with initial treatment or reexposure to untreated partners—if either is present, simply repeat the initial regimen 6, 4

• If compliance and partner treatment are confirmed, treat with metronidazole 2 g orally single dose OR tinidazole 2 g orally single dose PLUS azithromycin 1 g orally single dose (if azithromycin was not used initially) 4, 6

• Test for Trichomonas vaginalis using NAAT or culture of intraurethral swab or first-void urine, as this accounts for many cases of persistent urethritis 4, 6

Special Populations

Pregnancy

• Pregnant women should receive ceftriaxone 500 mg IM single dose for gonococcal infection 4

• Doxycycline and fluoroquinolones are absolutely contraindicated in pregnancy 4, 5

• For chlamydial coverage in pregnancy, use azithromycin 1 g orally single dose or erythromycin base 500 mg orally four times daily for 7 days 4, 5

HIV-Infected Patients

• HIV-infected patients should receive the same treatment regimen as HIV-negative patients—no modification is needed 4, 6

Common Pitfalls to Avoid

• Do not use azithromycin monotherapy (even at 2 g dose) due to cost, gastrointestinal side effects, and concerns about rapid emergence of resistance 4

• Do not substitute oral cephalosporins for pharyngeal gonorrhea—they have unacceptably low cure rates and ceftriaxone IM is required 4

• Do not treat based on symptoms alone—always document objective evidence of urethritis before initiating or repeating antimicrobial therapy 5, 6

• Do not use penicillins, tetracyclines, or macrolides as monotherapy for gonorrhea—N. gonorrhoeae in the United States is not adequately susceptible to these agents 4

• Report all suspected treatment failures to public health authorities, as surveillance for ceftriaxone resistance is essential for maintaining effective treatment guidelines 1