Treatment of Acute Urethritis in a Young Man with Recent Sexual Exposure
This patient requires dual therapy with both ceftriaxone AND azithromycin (or doxycycline) to cover both gonorrhea and chlamydia, making the correct answer a combination approach rather than any single agent listed. However, if forced to choose from the options provided, azithromycin (Option B) is the most appropriate single agent as it provides coverage for the most common cause of urethritis (Chlamydia trachomatis) and has activity against Mycoplasma genitalium. 1, 2
Why Dual Therapy is Standard of Care
The CDC explicitly recommends empiric treatment covering both N. gonorrhoeae and C. trachomatis for patients with confirmed urethritis, as co-infection is common and delaying treatment increases complications and transmission risk. 2
The recommended first-line regimen consists of:
- Ceftriaxone 250-500 mg IM as a single dose (covers gonorrhea) PLUS
- Doxycycline 100 mg orally twice daily for 7 days (covers chlamydia and M. genitalium) 2, 3, 4
Alternatively, azithromycin 1 g orally as a single dose can replace doxycycline, particularly when compliance is a concern or for directly observed therapy. 1, 5
Analysis of the Answer Choices
Option B: Azithromycin (Most Appropriate Single Agent)
- FDA-approved for urethritis and cervicitis due to C. trachomatis or N. gonorrhoeae 5
- Single-dose regimen (1 g orally) ensures compliance and allows directly observed treatment 1
- More effective than doxycycline for M. genitalium infections, which account for 13% of NGU cases 1, 6
- Clinical cure rates of 80-81% in randomized trials 6, 7
Option C: Ceftriaxone (Incomplete as Monotherapy)
- Essential for gonococcal coverage but inadequate alone because it does not cover C. trachomatis, which causes 24% of urethritis cases 2, 4, 6
- Must be combined with azithromycin or doxycycline 1, 2, 3
Option A: Gentamicin (Incorrect)
- Not a recommended agent for urethritis treatment 1
- No role in standard STI management
Option D: Nitrofurantoin (Incorrect)
- Used for uncomplicated cystitis, not urethritis 1
- Does not provide adequate coverage for sexually transmitted pathogens
Clinical Context and Diagnostic Confirmation
This patient has confirmed urethritis based on:
- Dysuria and urethral discharge (classic symptoms) 3, 4
- Recent sexual exposure with new partner (high-risk epidemiology) 1, 2
The CDC recommends initiating treatment as soon as possible after diagnosis, even before culture results are available, to achieve microbiologic cure, prevent transmission, and decrease complications such as epididymitis. 2
Critical Management Steps Beyond Antibiotics
- Test for both N. gonorrhoeae and C. trachomatis using nucleic acid amplification tests (NAATs), which are more sensitive than culture 1, 8
- Screen for HIV and syphilis as part of comprehensive STI evaluation 1, 2
- Treat all sexual partners within the preceding 60 days 1, 9
- Instruct patient to abstain from sexual intercourse for 7 days after therapy initiation and until symptoms resolve and partners are treated 1, 9, 3
- Repeat screening in 3 months due to high reinfection rates 8, 9, 3
Common Pitfalls to Avoid
- Do not treat for gonorrhea alone without chlamydia coverage, as co-infection occurs in a substantial proportion of cases 2
- Do not delay treatment waiting for test results in symptomatic patients with confirmed urethritis 2
- Do not use fluoroquinolones (like ofloxacin or levofloxacin) for gonorrhea due to widespread resistance, though they remain alternative agents for NGU 1
- Ensure medication is dispensed on-site and first dose is directly observed to maximize compliance 1
If Symptoms Persist After Treatment
- Re-confirm objective signs of urethritis (symptoms alone are insufficient for retreatment) 1, 9
- Rule out non-compliance or partner reinfection 9
- Test for Trichomonas vaginalis using intraurethral swab or first-void urine 1, 9
- Consider tetracycline-resistant Ureaplasma urealyticum 1, 9
- Treat with metronidazole 2 g orally as a single dose plus azithromycin 1 g (if not used initially) 9