A 28-year-old man presents to the STI clinic with dysuria and urethral discharge for 3 days. He reports unprotected sexual contact with a new partner 5 days ago. On examination, he has purulent urethral discharge. Gram stain of the urethral smear shows gram-negative intracellular diplococci within polymorphonuclear leukocytes. What is the most appropriate next step in management?

Explanation

## Diagnosis and Microbiology **Key Point:** Gram-negative intracellular diplococci (GNID) in polymorphonuclear leukocytes on Gram stain is pathognomonic for *Neisseria gonorrhoeae*. The clinical presentation of acute urethritis with purulent discharge 3–5 days post-exposure is classic for gonorrhea. ## Current Treatment Guidelines **High-Yield:** As of 2023, cephalosporin monotherapy (ceftriaxone 250 mg IM single dose) is the recommended first-line treatment for uncomplicated urogenital gonorrhea in India and globally [cite:WHO STI Guidelines 2023]. Fluoroquinolones are no longer recommended due to widespread resistance. Azithromycin monotherapy is no longer used for gonorrhea due to emerging resistance. **Clinical Pearl:** Ceftriaxone achieves excellent urethral and genital tract concentrations and has the lowest resistance rates among available agents. A single 250 mg IM dose is curative for uncomplicated urethritis. ## Syndromic Management Consideration **Key Point:** Although this patient has microbiologically confirmed gonorrhea, syndromic STI guidelines recommend concurrent treatment for *Chlamydia trachomatis* (azithromycin 1 g or doxycycline 100 mg BD × 7 days) because co-infection occurs in 20–40% of cases. However, the question asks for the "most appropriate next step," which is the definitive treatment of the confirmed diagnosis (gonorrhea). | Feature | Gonorrhea | Chlamydia | | --- | --- | --- | | Gram stain | GNID in PMNs | Gram-negative, intracellular | | Culture | Selective media (Thayer-Martin) | Difficult; PCR preferred | | Incubation | 2–7 days | 7–14 days | | Discharge | Purulent, copious | Mucopurulent, scanty | | Treatment | Ceftriaxone 250 mg IM | Azithromycin or doxycycline | ## Why Ceftriaxone Is Preferred 1. **Resistance profile:** Fluoroquinolone resistance in *N. gonorrhoeae* exceeds 50% in many regions; cephalosporin resistance remains <1%. 2. **Single-dose efficacy:** 250 mg IM achieves >99% cure rate for uncomplicated urethritis. 3. **Guideline-aligned:** Recommended by WHO, CDC, and Indian STI guidelines as first-line monotherapy.