A 33-year-old woman presents to the emergency department with foul-smelling vaginal discharge. She states that it started 1 day ago and has not improved with hygiene products. She is sexually active and uses condoms. She does not complain of any abdominal or pelvic pain but states she has some mild burning when urinating. Her temperature is 97.6°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 81/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for thick, white discharge from the cervix. There is no cervical motion or adnexal tenderness or masses. Some whitish discharge is noted from the urethra. A urine pregnancy test is negative. Which of the following is the most appropriate treatment for this patient?
Metronidazole
Ceftriaxone
Ceftriaxone and doxycycline
Ceftriaxone and azithromycin
Ceftriaxone and doxycycline
This nonpregnant woman is presenting with a thick, white cervical discharge, dysuria, and urethral discharge without cervical motion tenderness or adnexal tenderness which is concerning for urethritis without pelvic inflammatory disease. She should be treated with ceftriaxone and doxycycline to cover for the most common organisms.

The most common bacterial sexually transmitted infections include Neisseria gonorrhoeae and Chlamydia trachomatis. They can cause urethritis, cervicitis, and pelvic inflammatory disease. The diagnosis is made clinically with the appropriate history (vaginal discharge, high-risk sexual behavior) and physical exam (purulent cervical discharge +/- cervical motion tenderness, adnexal tenderness). The diagnosis should be confirmed with PCR; however, this should not delay treatment. Treatment should be given empirically, and the preferred regimen is ceftriaxone and doxycycline in men and nonpregnant women. In pregnant women, ceftriaxone and azithromycin may be used. Metronidazole is added empirically to cover for Trichomonas vaginalis.

Jennings and Krywko review pelvic inflammatory disease. They note that pelvic inflammatory disease is an inflammation of the upper genital tract due to an infection that can affect the uterus, fallopian tubes, and ovaries. They discuss the need for treatment and complications that can occur without treatment. They recommend timely diagnosis and treatment.

Incorrect Answers:
Answer A: Azithromycin is only indicated to cover chlamydia in pregnancy since doxycycline cannot be given to pregnant patients. Coverage for gonorrhea is also mandatory given this patient’s symptoms.

Answer B: Ceftriaxone is insufficient coverage for chlamydia or gonorrhea as chlamydia requires treatment with doxycycline, and gonorrhea requires double coverage from ceftriaxone in addition to doxycycline.

Answer C: Ceftriaxone and azithromycin is the preferred regimen to treat chlamydia and gonorrhea in pregnant patients since pregnant patients cannot receive doxycycline.

Answer E: Metronidazole is an appropriate treatment for bacterial vaginosis which presents with a fishy odor, white/gray vaginal discharge, and positive clue cells on wet mount.

Bullet Summary:
The treatment of choice for urethritis is ceftriaxone and doxycycline in nonpregnant patients.