Treatment of Suspected Gonorrhea and/or Chlamydia with Urethritis/Cervicitis
Initiate empiric dual therapy for both gonorrhea and chlamydia immediately without waiting for test results, using ceftriaxone 500 mg IM (single dose) plus doxycycline 100 mg orally twice daily for 7 days. 1, 2
Immediate Treatment Algorithm
First-Line Empiric Therapy
- Administer ceftriaxone 500 mg intramuscularly as a single dose for presumed gonorrhea 2
- Plus doxycycline 100 mg orally twice daily for 7 days for chlamydia (preferred over azithromycin due to superior efficacy) 2, 3
- Alternative for chlamydia: azithromycin 1 g orally as single dose (97% cure rate, but doxycycline is now preferred) 4, 5
The rationale for empiric dual therapy is critical: coinfection with gonorrhea occurs in 20-40% of chlamydia cases, and the 2-week duration of symptoms with yellowish discharge strongly suggests bacterial STI rather than other causes 4. The CDC explicitly recommends treating presumptively in high-prevalence settings (>5% gonorrhea prevalence) or when patient follow-up is uncertain 1.
Diagnostic Testing (Perform Concurrently, Not Sequentially)
- Obtain nucleic acid amplification tests (NAATs) for both Neisseria gonorrhoeae and Chlamydia trachomatis from urethral/cervical specimens (sensitivity 86.1%-100%, specificity 97.1%-100%) 3
- Screen for HIV, syphilis, and Trichomonas vaginalis at the same visit, as these are frequently co-occurring 4, 1
- Urinalysis findings are misleading: 74% of patients with STIs and pyuria have sterile urine cultures, so do not treat empirically for UTI based on pyuria alone 6, 7
Critical Management Requirements
Sexual Partner Management (Non-Negotiable)
- All sexual partners from the previous 60 days must receive empiric treatment with the same regimen, regardless of symptoms or test results 8, 4, 1
- Partners receive: ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 7 days 4
- Failure to treat partners results in reinfection rates up to 39% in some populations 4
Sexual Abstinence Protocol
- Mandatory abstinence from all sexual activity for 7 days after initiating treatment AND until all partners complete treatment 4, 1
- This applies even with single-dose therapy regimens 1
Mandatory Follow-Up Testing
- Retest at 3 months post-treatment for both gonorrhea and chlamydia to detect reinfection (not treatment failure) 4, 1
- This is essential because repeat chlamydia infections carry elevated risk for pelvic inflammatory disease, ectopic pregnancy, and infertility compared to initial infection 4
Common Pitfalls to Avoid
Do Not Misdiagnose as UTI
- Dysuria with yellowish discharge is STI until proven otherwise, not a urinary tract infection 9, 7
- Studies show 66% of women diagnosed with UTI in this context had negative urine cultures, representing massive overtreatment with wrong antibiotics 7
- Pyuria occurs in 37% of STI cases, with 74% having sterile urine 6
Do Not Wait for Test Results
- The CDC explicitly states treatment should be initiated before test results are available in sexually active young adults with discharge and dysuria 8, 1
- Waiting risks loss to follow-up and continued transmission 1
Do Not Use Azithromycin Monotherapy for Gonorrhea
- Ceftriaxone monotherapy is now the only recommended treatment for gonorrhea due to widespread resistance 2
- Azithromycin alone is inadequate for gonorrhea 2
Special Populations
Pregnancy Considerations
- Pregnant patients receive azithromycin 1 g orally (single dose) for chlamydia instead of doxycycline (which is contraindicated) 1
- Ceftriaxone dosing remains the same 1
HIV-Positive Patients
- Treatment regimens are identical to HIV-negative patients 8