In a 22-year-old man with acute dysuria and urethral discharge after recent sexual intercourse, who is afebrile and has an unremarkable examination, what is the most appropriate treatment?

Treatment of Acute Urethritis with Urethral Discharge

This patient requires dual therapy with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 7 days (or azithromycin 1 g orally as a single dose), making the answer both B (Azithromycin) and C (Ceftriaxone) – though if forced to choose a single agent from the options, ceftriaxone is essential and must not be omitted. 1, 2

Rationale for Dual Therapy

The clinical presentation of dysuria and urethral discharge following recent sexual contact in a young man indicates sexually transmitted urethritis, which requires coverage for both Neisseria gonorrhoeae and Chlamydia trachomatis 1, 2.

Key principle: Treatment for both gonorrhea and chlamydia is mandatory because:

• Chlamydial coinfection occurs in a substantial proportion of gonorrhea cases 3
• Testing delays mean treatment cannot wait for results 3
• Untreated chlamydia leads to complications including epididymitis and urethral stricture 3
• Most patients with gonorrhea have concurrent chlamydial infection that may be asymptomatic 1

Recommended Treatment Regimen

For gonorrhea coverage:

• Ceftriaxone 125-250 mg IM as a single dose 1, 4, 2

PLUS (mandatory addition) for chlamydia coverage:

• Doxycycline 100 mg orally twice daily for 7 days 1, 2
• OR Azithromycin 1 g orally as a single dose 1, 2

Why the Other Options Are Incorrect

Gentamicin (Option A): Not indicated for routine urethritis treatment. Gentamicin is reserved for specific situations such as suspected ceftriaxone-resistant gonorrhea (240 mg IM plus azithromycin 2 g), which is not the first-line approach 4.

Azithromycin alone (Option B): Insufficient as monotherapy. While azithromycin effectively treats chlamydia, it does not adequately cover gonorrhea, and using azithromycin alone for gonorrhea promotes resistance 1, 3.

Ceftriaxone alone (Option C): Incomplete treatment. While ceftriaxone covers gonorrhea, it does not treat chlamydia, leaving the patient at risk for persistent infection and complications 1, 3.

Nitrofurantoin (Option D): Not indicated for urethritis. Nitrofurantoin is a urinary tract antiseptic used for cystitis, not sexually transmitted urethritis 2.

Critical Management Steps

Immediate actions:

• Initiate empiric dual therapy immediately without waiting for test results 3, 2
• Obtain urethral swab for gonorrhea culture and chlamydia NAAT before treatment 2, 5
• Perform syphilis serology and HIV testing 3

Patient counseling:

• Abstain from sexual intercourse for 7 days after initiating therapy and until symptoms resolve 1, 3
• Abstain until all sexual partners are treated 1, 3

Partner management:

• All sexual partners within the preceding 60 days must be evaluated and treated empirically for both gonorrhea and chlamydia 1, 3
• Expedited partner therapy (providing prescriptions for partners) is recommended when partner evaluation is unlikely 1, 5

Common Pitfalls to Avoid

• Never treat gonorrhea without chlamydia coverage – coinfection rates are too high to risk monotherapy 1, 3
• Do not use quinolones (ciprofloxacin, ofloxacin) for gonorrhea due to widespread resistance 1
• Do not delay treatment waiting for test results when clinical criteria for urethritis are met 3, 2
• Do not use single-dose azithromycin alone for empiric urethritis treatment, as this misses gonorrhea and promotes resistance 3

Follow-Up Considerations

• No test-of-cure needed if treated with recommended regimens and symptoms resolve 1
• Retest in 3 months regardless of partner treatment status, as reinfection is common 1, 3
• If symptoms persist after treatment, evaluate for treatment failure, reinfection, or alternative pathogens (Mycoplasma genitalium, Trichomonas vaginalis) 1, 2