A 28-year-old man presents with purulent urethral discharge and dysuria for 3 days. On examination, there is a urethral meatus with mucopurulent exudate. Gram stain of urethral smear shows gram-negative diplococci within polymorphonuclear leucocytes. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis and Management **Key Point:** Gram-negative diplococci on Gram stain of urethral smear in a patient with acute urethritis is pathognomonic for *Neisseria gonorrhoeae*. Empiric treatment should be initiated immediately without awaiting culture results. ### Rationale for Correct Answer **High-Yield:** The combination of ceftriaxone 250 mg IM single dose + azithromycin 1 g orally single dose is the current WHO and CDC-recommended first-line regimen for uncomplicated urogenital gonorrhea [cite:WHO STI Guidelines 2016]. This dual therapy: 1. Covers *N. gonorrhoeae* with high efficacy 2. Provides coverage for concurrent *Chlamydia trachomatis* (present in ~30% of gonorrhea cases) 3. Reduces emergence of antimicrobial resistance 4. Achieves high cure rates (>95%) **Clinical Pearl:** The presence of gram-negative intracellular diplococci on Gram stain has >95% sensitivity and specificity for gonorrhea in symptomatic males. Treatment should not be delayed pending culture confirmation, as this increases risk of complications (epididymitis, prostatitis, urethral stricture) and transmission. ### Management Algorithm ```mermaid flowchart TD A[Acute urethritis + Gram-negative diplococci on Gram stain]:::outcome --> B{Presumptive gonorrhea diagnosis}:::decision B -->|Confirmed| C[Ceftriaxone 250 mg IM + Azithromycin 1 g PO]:::action C --> D[Single-dose regimen]:::action D --> E[Counsel on partner notification and STI screening]:::action E --> F[Test of cure: NAATs at 3-4 weeks if symptoms persist]:::outcome B -->|Gram stain negative| G[Consider Chlamydia, Ureaplasma, HSV]:::outcome ``` ### Partner Management - All sexual contacts within 60 days should be evaluated and treated - Expedited partner therapy (EPT) may be offered where legal - Patient counseling on barrier contraception and STI screening essential **Mnemonic:** **CAZA** = **C**eftriaxone + **A**zithromycin = **Z**ero resistance, **A**void complications