A 23-year-old man with painful urination and urethral discharge; urinalysis shows leukocyte esterase positive but is negative for blood and nitrites. Which treatment is appropriate?

• A. Penicillin V potassium 500 mg qid for 7 days
• B. One time dose of IM ceftriaxone 500 mg and doxycycline 100 mg twice daily for seven days
• C. Azithromycin 1 g stat
• D. Doxycycline 100 mg daily for 7 days

Answer: (B)

When a young man presents with urethral discharge and dysuria, the strongest approach is to treat empirically for the two most common causes of urethritis: Neisseria gonorrhoeae and Chlamydia trachomatis. The chosen regimen provides this dual coverage. A single dose of ceftriaxone given intramuscularly reliably treats gonorrhea, including strains with penicillin resistance. Adding doxycycline for seven days targets chlamydia, which often accompanies gonorrhea. This combination is preferred because it addresses both pathogens effectively, whereas doxycycline alone would miss gonorrhea, penicillin V would be ineffective due to resistance, and a one-time azithromycin dose doesn’t reliably cover gonorrhea. If there’s high suspicion of concurrent infection, obtain NAAT testing for both pathogens and treat partners, with counseling to avoid sex until therapy is completed.