The presence of intracellular Gram-negative diplococci on Gram stain of urethral discharge is highly indicative of Neisseria gonorrhoeae infection (gonorrhea). Due to increasing antimicrobial resistance and the high rate of co-infection with Chlamydia trachomatis, current CDC guidelines recommend dual therapy for uncomplicated gonococcal infections. The recommended regimen is a single intramuscular dose of Ceftriaxone (for gonorrhea) plus a single oral dose of Azithromycin (for potential chlamydial co-infection and to provide synergistic activity against gonorrhea). Azithromycin or Doxycycline monotherapy would be appropriate for Chlamydia alone but not for confirmed gonorrhea. Metronidazole is for anaerobic infections (e.g., trichomoniasis, bacterial vaginosis) and Ciprofloxacin is no longer recommended for gonorrhea due to widespread resistance.
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