What is the recommended treatment for a patient with no prior history of STIs, presenting with green penile discharge and a burning sensation, following recent unprotected sexual activity?

Treatment for Gonorrhea and Chlamydia Co-Infection

This patient requires immediate empiric treatment with ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and chlamydia. 1

Clinical Presentation Analysis

Green penile discharge with burning sensation following unprotected sexual activity is pathognomonic for gonococcal urethritis, though chlamydial co-infection occurs in a substantial proportion of cases. 2

• Gonorrhea is the primary diagnosis based on the purulent green discharge, which is highly specific for Neisseria gonorrhoeae infection 2
• Presumptive chlamydia treatment is mandatory because co-infection rates are high and testing results will not be immediately available 3, 1
• The syndromic approach to urethral discharge performs exceptionally well, allowing accurate treatment at first encounter with rapid cure using effective drugs 2

Recommended Treatment Regimen

For Gonorrhea:

• Ceftriaxone 500 mg IM as a single dose (for patients weighing <150 kg) 1
• This represents updated 2021 CDC guidance moving to ceftriaxone monotherapy, abandoning the previous dual therapy requirement 1
• Ceftriaxone can be reconstituted with 1% lidocaine solution (without epinephrine) for IM injection to reduce injection pain 4

For Presumptive Chlamydia:

• Doxycycline 100 mg orally twice daily for 7 days is the preferred first-line treatment 1
• Alternative regimens include erythromycin base 500 mg orally 4 times daily for 7 days if doxycycline is contraindicated 3

Critical Management Steps

Partner Management:

• All sexual partners within 60 days before symptom onset must be evaluated and treated for both gonorrhea and chlamydia 3
• If the patient's last sexual contact was >60 days before symptoms, treat the most recent partner 3
• Patient must abstain from sexual intercourse until both patient and all partners complete therapy and are symptom-free 3

Follow-Up Protocol:

• No test-of-cure is required for uncomplicated urogenital gonorrhea treated with recommended ceftriaxone regimens 3, 5
• Retest at 3 months after treatment to detect reinfection, which is common and represents the majority of post-treatment positive tests rather than treatment failure 5, 1
• If the patient doesn't return at 3 months, perform opportunistic retesting whenever they seek care within the following 12 months 5

When Test-of-Cure IS Required:

• Persistent symptoms after treatment completion warrant culture with antimicrobial susceptibility testing 3, 5
• Pharyngeal gonorrhea requires test-of-cure due to lower cure rates 5, 1

Common Pitfalls to Avoid

• Do not wait for test results before initiating treatment in symptomatic patients with classic presentation—immediate empiric therapy prevents complications and transmission 6, 2
• Do not treat gonorrhea without covering chlamydia—co-infection is common and undertreating chlamydia leads to complications including epididymitis and transmission 3, 2
• Do not confuse 3-month retesting with test-of-cure—the former detects reinfection (which is common), while the latter detects treatment failure (which is rare with recommended regimens) 5
• Do not skip partner notification and treatment—most reinfections result from untreated partners, and effective partner management is essential for STI control 3, 1

Additional Testing Considerations

While treating empirically, obtain diagnostic testing for:

• Gonorrhea and chlamydia via nucleic acid amplification testing (NAAT) to confirm diagnosis and facilitate partner notification 3, 7
• HIV, syphilis, and hepatitis B serology as part of comprehensive STI screening in all patients with gonorrhea 1