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Gonorrhea + Chlamydia (Urethritis / Cervicitis)

STI / Outpatient

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1. Clinical Syndrome

Symptomatic urethritis (men) or cervicitis (women) — dysuria, urethral discharge, vaginal discharge, intermenstrual or post-coital bleeding — caused by Neisseria gonorrhoeae and/or Chlamydia trachomatis. Often asymptomatic, particularly in women + extragenital sites (pharyngeal, rectal).

Empiric dual treatment for GC + CT is standard because co-infection is common (~20–40% of GC infections have concurrent CT), NAAT turnaround is often >24 h, and risk-of-loss-to-followup is high. NAAT-positive single-pathogen infections are treated pathogen-directed.

Excludes: non-gonococcal / non-chlamydial urethritis (M. genitalium, Trichomonas — separate workup), PID (upper-tract — separate syndrome), proctitis / pharyngitis (extragenital variants — same drugs, slightly different cure rates), neonatal ophthalmia / disseminated gonococcal infection (separate management).

2. Pathogens

Consider the patient: Sexually active, esp <25 y, MSM, multiple partners, prior STI, new partner in 60 d.

Consider the case: Always NAAT for both GC + CT (urine men; vaginal swab women — patient or clinician-collected). Add rectal + pharyngeal NAAT in exposed individuals. Treat empirically on symptoms or contact tracing; don't wait for NAAT. HIV + syphilis serology at every STI visit (high co-incidence). Trichomonas NAAT in women.

Common

    • Neisseria gonorrhoeae

      Gram-negative diplococcus. Resistance to ciprofloxacin, azithromycin, tetracyclines, and increasingly cefixime is rising — IM ceftriaxone is the only reliable first-line.

    • Chlamydia trachomatis

      Obligate intracellular; serovars D–K (urogenital), L1–L3 (LGV — proctocolitis in MSM, needs extended duration).

3. Empiric Therapy

TierFirst choiceAlternativesDurationComments
Outpatient
  • 500 mg (1 g if BMI ≥150 kg / 330 lb) · single dose · IM · single dose

    GC empiric coverage. **Dose increased from 250 mg to 500 mg in CDC 2021** due to rising MIC creep.

  • 100 mg · PO BID · PO · 7 days

    CT empiric coverage. Now preferred over azithromycin single-dose (superior cure rate, especially rectal CT).

  • 1 g · single dose · PO

    CT — only if doxycycline contraindicated. Pregnancy first-line for CT. Inferior for rectal CT.

  • Cefixime 800 mg · single dose · PO

    GC alternative only if ceftriaxone unavailable + cervical/urethral only (not pharyngeal — failure rates too high). NOT for pharyngeal GC.

  • 240 mg IM × 1 + azithromycin 2 g PO × 1 · single dose combination · IM/PO

    Cephalosporin-allergy GC regimen. Less effective; test of cure mandatory.

Single-dose IM ceftriaxone + 7-day doxycycline**CDC 2021 dual therapy:** ceftriaxone 500 mg IM × 1 PLUS doxycycline 100 mg PO BID × 7 d (CT coverage). **Azithromycin 1 g** no longer co-administered routinely (resistance, inferior cure). **Treat partners** (within 60 d) — expedited partner therapy (EPT) where legally permitted. **Abstain from sex** 7 d after treatment + until all partners treated.

4. Directed Therapy

NAAT positive for GC only: ceftriaxone 500 mg IM × 1. No CT treatment needed if NAAT negative.

NAAT positive for CT only: doxycycline 100 mg PO BID × 7 d. No GC treatment needed.

Disseminated gonococcal infection (DGI) — fever, polyarthralgia / tenosynovitis, septic arthritis, dermatitis (sparse pustular lesions on extremities), or rarely endocarditis / meningitis: ceftriaxone 1 g IV/IM daily × 7+ d (longer for endocarditis or meningitis). See septic-arthritis for arthritis-only management.

Persistent / recurrent urethritis after appropriate treatment: think Mycoplasma genitalium (NAAT — if positive: moxifloxacin × 7 d, or doxy 7 d + azithro 4 d if macrolide-sensitive), Trichomonas, or non-adherence / reinfection.

5. Monitoring

Test-of-cure (TOC):

  • Genital GC + CT: NOT routinely (rescreen at 3 months for reinfection — high rate).
  • Pharyngeal GC: TOC NAAT at 7–14 d (per CDC 2021).
  • Pregnancy: TOC 3–4 weeks post-treatment.
  • Treatment failure suspected: NAAT + culture with susceptibility (culture only available at specialized labs).

Rescreen at 3 months for all treated patients (re-infection common). Partner treatment + HIV/syphilis testing at each visit. PrEP counseling for HIV-negative patients with STI.

Toxicity: ceftriaxone — biliary sludge, rare anaphylaxis. Doxycycline — esophagitis, photosensitivity (counsel summer sun protection). Azithromycin — QT prolongation, GI upset.

Pearls

500 mg IM ceftriaxone (not 250) is current CDC. Doxycycline 7 d (not azithromycin 1 g) is preferred CT regimen. Treat empirically on symptoms or contact — don't wait for NAAT. Pharyngeal GC = ceftriaxone only; oral regimens fail. LGV (rectal CT in MSM) = doxy × 21 days. Always test/treat for HIV + syphilis at the same visit. EPT for partners where legal. Rescreen at 3 months.

References