Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
cephalosporin monotherapy or gentamicin plus azithromycin
For symptomatic people with initial Gram stain showing gram-negative intracellular diplococci, presumptive treatment for both gonococcal and nongonococcal urethritis should be given.[1][32][42][43]
The Centers for Disease Control and Prevention recommends a single dose of intramuscular ceftriaxone for uncomplicated gonorrhea.[1]
If ceftriaxone is not available, oral cefixime is a suitable alternative agent.[1] Consult specialist for guidance on other alternative injectable cephalosporin options.
In patients who have a cephalosporin allergy, intramuscular gentamicin in a single dose plus a high dose of azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of these regimens.[1]
Urethritis may facilitate HIV transmission. Treatment is the same in people with HIV as in people without HIV.[1]
All sex partners within the last 60 days should be referred for evaluation and possible treatment.[1][44]
[ 
]
The management of a patient’s sex partners is an important consideration to prevent reinfection and further transmission.[47][Figure caption and citation for the preceding image starts]: Gram stain of urethral exudate showing gram-negative diplococci and polymorphonuclear leukocytesAdapted from Public Health Image Library, CDC; Jacobs N, 1974 [Citation ends].
Primary options
ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose
Secondary options
cefixime: 800 mg orally as a single dose
Tertiary options
gentamicin: 240 mg intramuscularly as a single dose
and
azithromycin: 2 g orally as a single dose
cephalosporin monotherapy
For symptomatic people with initial Gram stain showing gram-negative intracellular diplococci, presumptive treatment for both gonococcal and nongonococcal urethritis should be given.[1][32][43]
Pregnant women should be treated with ceftriaxone monotherapy first-line.[1]
Consultation with an infectious disease specialist is recommended if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with these agents.
Pregnant women should be retested to ensure cure, preferably with a nucleic acid amplification test such as ligase chain reaction or polymerase chain reaction of urethral discharge and/or urine sediment. Chlamydia test of cure is recommended 4 weeks after treatment, with a retest at 3 months. Retest for gonorrhea is recommended at 3 months.[1]
Urethritis may facilitate HIV transmission. Treatment is the same in people with HIV as in people without HIV.[1]
All sex partners within the last 60 days should be referred for evaluation and possible treatment.[1][44]
[ ]
The management of a patient’s sex partners is an important consideration to prevent reinfection and further transmission.[47][Figure caption and citation for the preceding image starts]: Gram stain of urethral exudate showing gram-negative diplococci and polymorphonuclear leukocytesAdapted from Public Health Image Library, CDC; Jacobs N, 1974 [Citation ends].
Primary options
ceftriaxone: 500 mg intramuscularly as a single dose
doxycycline or azithromycin
Patients are initially treated for nongonococcal urethritis (NGU) alone with all symptomatic people having NAAT testing for Chlamydia trachomatis, Mycoplasma genitalium, and Neisseria gonorrhoea, even if initial Gram stain tests are negative for evidence of gonococci.[27]
Presumptive treatment with doxycycline is recommended, as this drug is highly effective for C trachomatis and has some activity against M genitalium.[1]
Azithromycin should be considered as a secondary treatment option due to increasing reports of treatment failure and macrolide antimicrobial resistance with M genitalium.[29][48] A multi-day azithromycin dosing regimen may protect against inducingM genitalium resistance.[1]
Urethritis may facilitate HIV transmission. Treatment is the same in people with HIV as in people without HIV.[1]
All sex partners within the last 60 days should be referred for evaluation and possible treatment.[1][44]
[ ]
The management of a patient’s sex partners is an important consideration to prevent reinfection and further transmission.[47]
If subsequent nucleic acid amplification testing (NAAT) and/or culture testing results are available, the choice of antibiotic for definitive antibiotic therapy is based on the local epidemiology of specific infections and antimicrobial sensitivity patterns. If a NAAT is positive for gonorrhea, a culture should be performed before antigonococcal treatment is added.[29] Consultation with an infectious disease specialist is recommended.
Primary options
doxycycline: 100 mg orally twice daily for 7 days
Secondary options
azithromycin: 1 g orally as a single dose; or 500 mg orally as a single dose, followed by 250 mg once daily for 4 days
azithromycin or amoxicillin
Pregnant women should be treated with azithromycin first-line.[1]
Amoxicillin is an alternative treatment if chlamydial infection is detected.[1]
Doxycycline and flouroquinolones are not recommended in pregnancy.
Consultation with an infectious disease specialist is recommended if the patient has any considerations that preclude treatment with these regimens.
Pregnant women should be retested to ensure cure, preferably with a nucleic acid amplification test such as ligase chain reaction or polymerase chain reaction of urethral discharge and/or urine sediment. Chlamydia test of cure is recommended 4 weeks after treatment, with a retest at 3 months. Retest for gonorrhea is recommended at 3 months.[1]
Urethritis may facilitate HIV transmission. Treatment is the same in people with HIV as in people without HIV.[1]
All sex partners within the last 60 days should be referred for evaluation and possible treatment.[1][44]
[ ]
The management of a patient’s sex partners is an important consideration to prevent reinfection and further transmission.[47]
If subsequent nucleic acid amplification testing (NAAT) and/or culture testing results are available, the choice of antibiotic for definitive antibiotic therapy is based on the local epidemiology of specific infections and antimicrobial sensitivity patterns. If a NAAT is positive for gonorrhea, a culture should be performed before antigonococcal treatment is added.[29] Consultation with an infectious disease specialist is recommended.
Primary options
azithromycin: 1 g orally as a single dose; or 500 mg orally as a single dose, followed by 250 mg once daily for 4 days
Secondary options
amoxicillin: 500 mg orally three times daily for 7 days
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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