Uncomplicated Gonococcal Urethritis: The Daily PANCE Blueprint
A 24-year-old man presents with 3 days of dysuria and a thick, purulent urethral discharge. He reports condomless sex with a new partner two weeks ago. He is afebrile, with no joint pain, no rash, and no testicular tenderness. A nucleic acid amplification test of the urethral discharge is positive for Neisseria gonorrhoeae; the chlamydia result is still pending. He weighs 78 kg and has no drug allergies. Which of the following is the most appropriate pharmacotherapy?
A. Ceftriaxone 250 mg intramuscularly once plus azithromycin 1 g orally once
B. Cefixime 800 mg orally once
C. Azithromycin 2 g orally once
D. Ceftriaxone 500 mg intramuscularly once
E. Ceftriaxone 500 mg intramuscularly once plus doxycycline 100 mg orally twice daily for 7 days
Answer and topic summary
The answer is E. Ceftriaxone 500 mg intramuscularly once plus doxycycline 100 mg orally twice daily for 7 days
Per the CDC 2021 STI Treatment Guidelines, uncomplicated urogenital gonorrhea in an adult under 150 kg is treated with ceftriaxone 500 mg intramuscularly as a single dose (1 g if 150 kg or more). Because chlamydial coinfection has not been excluded here, doxycycline 100 mg orally twice daily for 7 days must be added — which is what makes the combination, not ceftriaxone alone, the single best answer.
Two changes trip people up, and both are in this option set. First, the dose went UP from 250 mg to 500 mg. Second, azithromycin is no longer given routinely with ceftriaxone for gonorrhea — the old dual-therapy regimen was dropped for antimicrobial stewardship, so ceftriaxone 250 mg plus azithromycin 1 g is the outdated 2015 regimen and is wrong on both counts. If you learned this from an older resource, this is the update to carry forward.
Ceftriaxone 500 mg alone would be correct only if chlamydia had been excluded, and it has not. Cefixime 800 mg orally is an alternative only when ceftriaxone cannot be given, and it is less effective at pharyngeal sites. Azithromycin 2 g orally is not a recommended treatment for gonorrhea because of resistance and poor tolerability. Also counsel on treatment of recent sexual contacts, abstinence for 7 days after therapy, and testing for HIV and syphilis; a test-of-cure is not needed for uncomplicated urogenital infection treated with ceftriaxone.
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