What is the most appropriate treatment for a patient with a 2-day history of dysuria and urethral discharge after recent sexual activity with a new partner?

Treatment of Urethritis with Dysuria and Urethral Discharge After Recent Sexual Activity

This patient requires dual therapy with ceftriaxone 125 mg IM PLUS azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days) to cover both gonorrhea and chlamydia. 1, 2

Clinical Reasoning

The presentation of dysuria and urethral discharge following recent sexual activity with a new partner is classic for sexually transmitted urethritis, most commonly caused by Neisseria gonorrhoeae and/or Chlamydia trachomatis. 3, 4

Why Dual Therapy is Essential

• Co-infection is extremely common: Chlamydia and gonorrhea frequently occur together at genital sites, making empirical treatment for both pathogens mandatory even before test results are available. 1, 2

• CDC guidelines explicitly recommend: Treatment for both N. gonorrhoeae and C. trachomatis infections should be initiated presumptively in all patients presenting with urethritis and recent sexual exposure. 5

• Prevention of complications: Untreated chlamydial infection can lead to serious sequelae, and treating only gonorrhea would miss concurrent chlamydia in up to 30-40% of cases. 5, 1

Recommended Treatment Regimen

First-line therapy:

• Ceftriaxone 125 mg IM (single dose) for gonorrhea coverage 5, 2
• PLUS Azithromycin 1 g orally (single dose) OR Doxycycline 100 mg orally twice daily for 7 days for chlamydia coverage 5, 2

Why Each Answer Choice is Right or Wrong

Option B (Azithromycin alone) is INCORRECT because:

• Azithromycin 1 g alone cures only 93% of gonococcal infections and is not recommended as monotherapy for gonorrhea due to resistance concerns. 5, 2
• While azithromycin covers chlamydia effectively, it provides inadequate gonorrhea coverage when used alone. 2

Option C (Ceftriaxone alone) is INCORRECT because:

• Ceftriaxone provides excellent gonorrhea coverage but does not treat chlamydia. 5, 2
• Missing concurrent chlamydial infection would leave the patient at risk for persistent symptoms and transmission. 1, 2

Option A (Gentamicin) is INCORRECT because:

• Gentamicin has no role in treating urethritis caused by gonorrhea or chlamydia. 5

Option D (Nitrofurantoin) is INCORRECT because:

• Nitrofurantoin is used for urinary tract infections, not sexually transmitted urethritis. 5

Critical Management Steps Beyond Initial Treatment

Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia, even without symptoms. 5, 1, 2
• If the last sexual contact was >60 days before diagnosis, the most recent partner should still be treated. 5, 1

Sexual Abstinence

• Both patient and partner must abstain from sexual intercourse until 7 days after therapy initiation and complete symptom resolution to prevent reinfection. 1, 2

Additional Testing

• All patients with sexually transmitted urethritis should receive testing for syphilis and HIV at the time of diagnosis. 1, 6

Follow-Up Considerations

• Patients treated with recommended regimens do not need a test of cure unless symptoms persist. 5, 2
• Consider retesting at 3 months due to high rates of reinfection (not treatment failure). 5, 2
• Persistent symptoms after treatment warrant culture with antimicrobial susceptibility testing. 5, 2

Common Pitfalls to Avoid

• Do not use azithromycin monotherapy for presumed gonorrhea—resistance is a major concern and cure rates are inadequate. 5, 2
• Do not treat only for gonorrhea without chlamydia coverage—co-infection rates are too high to justify single-pathogen treatment. 1, 2
• Do not forget partner treatment—reinfection from untreated partners is the most common cause of treatment failure. 1, 2
• Do not use quinolones (ciprofloxacin, ofloxacin) in men who have sex with men or those with recent travel to areas with quinolone-resistant gonorrhea. 5, 2