- Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS more...
Administer antibiotics to patients with positive Gram stain or culture results and to all sexual partners of those patients, regardless of symptoms. Also treat patients with negative Gram stain results and a history consistent with urethritis who are not likely to return for follow-up and/or are likely to continue transmitting infection (eg, prostitutes, persons who abuse drugs, homeless persons). The latter group may best be served with single-dose therapies (see below).
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
The antimicrobial options in the treatment of urethritis include parenteral ceftriaxone, oral azithromycin, oral ofloxacin, oral ciprofloxacin, oral cefixime, oral doxycycline, and parenteral spectinomycin. Azithromycin and doxycycline have been proven equally efficacious in treating C trachomatis infections. Ofloxacin and azithromycin are effective for nongonococcal urethritis (NGU), whereas ciprofloxacin is ineffective against chlamydial infection. Combinations of probenecid with penicillin, amoxicillin, or ampicillin are no longer used because of resistance. Conversely, the macrolides, including erythromycin, and tetracyclines all have similar effectiveness in NGU. The incidence of quinolone-resistant N gonorrhea is high in Asian and Pacific nations and is rising in the West Coast of the United States. Obtaining a recent travel history may help direct therapy.
Patients with proven gonococcal urethritis should be empirically treated for C trachomatis infection. Empiric treatment is less expensive than culture in any population whose coinfection rate is at least 10%. Single-dose empiric treatments offer an advantage in patients who are noncompliant or unlikely to return for follow-up. Single-dose regimens include azithromycin for C trachomatis and cefixime, ceftriaxone, ciprofloxacin, ofloxacin, or levofloxacin for N gonorrhea.
A single dose of metronidazole plus a 7-day course of erythromycin is recommended for NGU recurrence. Antibiotic therapy is recommended for affected individuals and sexual partners of individuals with documented trichomonal infection, even if asymptomatic.
In 2-g dose, treats both gonococcal urethritis and NGU. Treatment of choice and is well tolerated by most patients. Eight large tabs are required, and liquid is also available.
Used for gonococcal urethritis only. Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Treats gonococcal urethritis only. By binding to 1 or more of the penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Treats gonococcal urethritis only. Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but offers no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
Treats gonococcal urethritis only. Penetrates prostate well and is effective against N gonorrhea and C trachomatis. A derivative of pyridine carboxylic acid with broad-spectrum bactericidal effect.
Treats NGU only. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
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