A 28-year-old man with acute urethritis presents with purulent urethral discharge. Gram stain of the discharge shows gram-negative intracellular diplococci within neutrophils. What is the drug of choice for treatment?

Explanation

## Gonococcal Urethritis — Gram Stain and Treatment **Key Point:** Gram-negative intracellular diplococci (GNID) within neutrophils on urethral Gram stain is pathognomonic for *Neisseria gonorrhoeae*. Ceftriaxone is the current first-line agent due to widespread fluoroquinolone and tetracycline resistance. ### Gram Stain Findings in Gonorrhea **High-Yield:** The classic Gram stain appearance of gonorrhea: - **Gram-negative** diplococci - **Intracellular** location (within polymorphonuclear leukocytes/neutrophils) - **Kidney bean or coffee bean** morphology - **Sensitivity:** 90–95% in symptomatic urethritis; lower in asymptomatic or cervicitis ### Current Treatment Guidelines **Mnemonic:** **GNID = Gonorrhea Needs Immediate Cephalosporin** (ceftriaxone is the DOC). 1. **Ceftriaxone 250 mg IM once** — current CDC and WHO first-line for uncomplicated gonorrhea 2. Covers both susceptible and moderately resistant strains 3. Excellent urethral and genital tract penetration 4. Often combined with azithromycin or doxycycline for concurrent chlamydia (if not ruled out) ### Why Resistance Emerged | Agent | Status | Reason for Decline | | --- | --- | --- | | Penicillin | Obsolete | Widespread resistance (PPNG) since 1980s | | Tetracyclines (doxycycline) | Resistance common | 30–40% resistance in many regions | | Fluoroquinolones (ciprofloxacin) | Resistance widespread | QRNG (quinolone-resistant N. gonorrhoeae) >50% in many countries | | Spectinomycin | Backup only | Less effective; resistance emerging; not first-line | | **Cephalosporins (ceftriaxone)** | **First-line** | **Remains highly effective; resistance still rare** | **Clinical Pearl:** Even if Gram stain is diagnostic for gonorrhea, always test for concurrent *Chlamydia trachomatis* (30–50% co-infection rate). Many guidelines recommend dual therapy: ceftriaxone + azithromycin or doxycycline. **Warning:** Do NOT use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea — resistance is too high. Do NOT rely on tetracyclines (doxycycline) as monotherapy — resistance is common and increasing. [cite:CDC STI Treatment Guidelines 2021; Harrison 21e Ch 137]