What is the next step in managing a patient with gonorrhea who has been taking cefixime (cephalosporin antibiotic) for 5 days, has no discharge, but still experiences sharp dysuria if not adequately hydrated, with no fever or other systemic symptoms?

Management of Persistent Dysuria After Cefixime Treatment for Gonorrhea

This patient requires immediate re-evaluation with culture and antimicrobial susceptibility testing, followed by re-treatment with ceftriaxone 250 mg IM plus azithromycin 1 g orally, as cefixime monotherapy violates current CDC dual therapy recommendations and has suboptimal efficacy. 1, 2, 3

Critical Problems with Current Management

The patient was treated incorrectly from the start. Cefixime should never be used as monotherapy for gonorrhea—CDC guidelines mandate dual therapy with azithromycin 1 g orally or doxycycline 100 mg twice daily for 7 days to address chlamydial coinfection (present in 10-50% of cases) and potentially delay cephalosporin resistance. 3, 4, 5

Why Cefixime Was Suboptimal

• Cefixime provides only 97.1-97.4% cure rates for urogenital/anorectal gonorrhea compared to 99.1% with ceftriaxone, and has declining susceptibility with rising MICs. 2, 3
• CDC removed cefixime from first-line recommendations in 2012 due to documented treatment failures in Europe and rising resistance patterns. 1, 2
• Cefixime is only acceptable when ceftriaxone is unavailable, and requires mandatory test-of-cure at 1 week. 1, 3

Immediate Next Steps

1. Obtain Cultures Before Re-Treatment

Collect specimens from all potentially infected sites (urethra, pharynx if indicated) for culture with antimicrobial susceptibility testing. 1, 3

• Persistent symptoms after treatment with a recommended regimen suggest either treatment failure (rare) or reinfection (more common), but given the suboptimal initial regimen, treatment failure is more likely here. 1
• Culture is essential because NAAT cannot distinguish between viable organisms and residual DNA from dead bacteria. 1
• If NAAT is used initially and positive, confirm with culture and perform phenotypic antimicrobial susceptibility testing. 1, 3

2. Re-Treat Immediately with Recommended Dual Therapy

Administer ceftriaxone 250 mg IM plus azithromycin 1 g orally as a single dose, preferably simultaneously and under direct observation. 1, 3, 4, 5

• This is the only CDC-recommended first-line regimen for gonorrhea treatment. 3, 4, 5
• Do not wait for culture results before re-treating, as persistent symptoms warrant immediate intervention. 1, 3
• The combination addresses both potential treatment failure and possible chlamydial coinfection. 3, 4

3. Mandatory Test-of-Cure

Perform test-of-cure at 1 week (7 days) after re-treatment using culture (preferred) or NAAT. 1, 3

• This is mandatory given the treatment failure scenario and use of cefixime initially. 1, 3
• Culture allows antimicrobial susceptibility testing if still positive. 1, 3
• If NAAT is positive at follow-up, confirm with culture and perform phenotypic susceptibility testing. 3

Additional Considerations

Evaluate for Alternative Diagnoses

The dysuria that improves with hydration suggests possible non-gonococcal urethritis from Chlamydia trachomatis or other organisms. 1

• Persistent urethritis after gonorrhea treatment may be caused by C. trachomatis, which is why dual therapy is essential. 1, 3
• The absence of discharge after 5 days suggests the gonococcal component may have partially responded, but incomplete treatment or coinfection remains. 1

Partner Management

Evaluate and treat all sexual partners from the preceding 60 days with the recommended dual therapy regimen (ceftriaxone 250 mg IM plus azithromycin 1 g orally). 1, 3

• Most post-treatment infections result from reinfection rather than treatment failure, indicating need for partner treatment. 1
• Partners should receive the same dual therapy regardless of symptoms or test results. 3
• Consider expedited partner therapy with oral combination (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation. 1, 3

Screen for Other STIs

Test for syphilis by serology and HIV at this visit. 1, 3

• Gonorrhea facilitates HIV transmission, making co-testing essential. 1, 3
• Screening for syphilis should be performed when gonorrhea is detected. 1

Counsel on Reinfection Risk

Advise the patient to be retested 3 months after treatment due to high reinfection rates. 4, 5, 6, 7

• Repeat N. gonorrhoeae infection is prevalent among patients treated for gonorrhea in preceding months. 4, 5
• Most post-treatment infections result from reinfection, not treatment failure. 1
• Instruct patient to avoid sexual intercourse until both patient and partner(s) complete therapy and are asymptomatic. 1

Common Pitfalls to Avoid

• Never use cefixime as monotherapy—always combine with azithromycin or doxycycline. 2, 3, 8
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy and risks rapid resistance emergence. 3
• Never use fluoroquinolones for gonorrhea treatment due to widespread resistance. 1, 3
• Do not assume symptom resolution equals cure when suboptimal regimens were used—test-of-cure is mandatory. 1, 3

If Treatment Failure Confirmed After Re-Treatment

Consult infectious disease specialist immediately and report to local/state health department within 24 hours. 1, 3

• Recommended salvage regimens include gentamicin 240 mg IM plus azithromycin 2 g orally, or ertapenem 1 g IM for 3 days. 3
• Retain isolates for further testing and report to CDC through local health department. 1