What empirical regimen should I prescribe for a male patient with dysuria and penile discharge after unprotected sex, with no known drug allergies, to cover Neisseria gonorrhoeae and Chlamydia trachomatis?

Empiric Treatment for Suspected Gonorrhea and Chlamydia Urethritis

Prescribe Ceftriaxone 250 mg intramuscularly as a single dose PLUS Doxycycline 100 mg orally twice daily for 7 days. This dual-therapy regimen provides comprehensive coverage for both Neisseria gonorrhoeae and Chlamydia trachomatis, which are the two most common bacterial causes of sexually transmitted urethritis in men under 35 years of age 1.

Why Dual Coverage is Mandatory

• Co-infection rates are extremely high: Among men with confirmed gonorrhea, 20% are simultaneously infected with chlamydia; among women with gonorrhea, the co-infection rate reaches 42% 2.
• Empiric treatment before culture results is explicitly recommended by the CDC to achieve microbiologic cure, prevent transmission, and reduce complications such as epididymitis 1, 3.
• Delaying treatment until culture results increases risk of ongoing transmission and complications 1.
• Treating gonorrhea alone without chlamydia coverage is inadequate because urethritis is often accompanied by asymptomatic co-infection with both pathogens 1, 3.

The Specific Regimen

For Gonorrhea Coverage

• Ceftriaxone 250 mg intramuscularly as a single dose 1, 3.
• Ceftriaxone is the only remaining first-line agent for gonorrhea due to widespread fluoroquinolone resistance 1.

For Chlamydia Coverage

• Doxycycline 100 mg orally twice daily for 7 days 1, 3, 4.
• Alternative: Azithromycin 1 g orally as a single dose if compliance with a 7-day regimen is unlikely 1, 3.
• Azithromycin has the advantage of directly observed single-dose therapy and superior activity against Mycoplasma genitalium, which causes approximately 13% of non-gonococcal urethritis cases 1, 3.

Critical Management Steps

Medication Dispensing

• Dispense medications on-site in the clinic and directly observe the first dose to maximize compliance 3, 1.

Sexual Abstinence

• The patient must abstain from sexual intercourse for 7 days after therapy initiation AND until complete symptom resolution 1, 3.
• This prevents reinfection and ongoing transmission 1.

Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated empirically with the same dual-therapy regimen before their test results are available 5, 6.
• If the last sexual contact was more than 60 days ago, the most recent partner should still be treated 5.
• Partners should receive treatment for both gonorrhea and chlamydia regardless of the specific pathogen identified in the index patient 3.

Comprehensive STI Screening

• Test for HIV and syphilis as part of the comprehensive STI evaluation 1, 6.
• Perform nucleic acid amplification tests (NAATs) for both N. gonorrhoeae and C. trachomatis on first-void urine or urethral swab 6, 3.

Common Pitfalls to Avoid

• Do not treat for gonorrhea alone: Co-infection is too common to omit chlamydia coverage 1, 2.
• Do not use fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) for gonorrhea: Widespread resistance makes these agents unreliable 1.
• Do not use azithromycin alone for gonorrhea: At the 1 g oral dose, azithromycin is insufficiently effective against gonorrhea 3.
• Do not forget partner treatment: Reinfection is the primary cause of treatment failure 5, 7.

Follow-Up Considerations

• Patients should return for evaluation only if symptoms persist or recur after completing therapy 3.
• Routine test-of-cure is not necessary for patients treated with recommended regimens 3.
• If symptoms persist, reconfirm objective signs of urethritis before retreatment 3, 1.
• Consider testing for Trichomonas vaginalis and tetracycline-resistant Ureaplasma urealyticum in cases of treatment failure 3, 1.

Special Considerations for This Patient

Since this patient has no known drug allergies, the standard dual-therapy regimen is appropriate without modification 1. The combination of intramuscular ceftriaxone and oral doxycycline provides optimal coverage, compliance, and clinical outcomes 1, 3.