Situation: A 27-year-old man comes to the social hygiene clinic of a city health office with a painless ulcer on his penis for 1 week and a purulent urethral discharge for 3 days. His rapid plasma reagin (RPR) and treponemal tests are both reactive, and a urethral swab is positive for Neisseria gonorrhoeae. He has one regular female partner and no drug allergies. His partner comes in for testing. She is 10 weeks pregnant, has no drug allergies, and tests positive for both gonorrhea and chlamydia; her syphilis testing and treatment are managed separately. Which treatment for her gonorrhea and chlamydia should the nurse expect to be ordered?

Two rules apply at once. Gonorrhea is treated with intramuscular ceftriaxone, and chlamydia is treated with doxycycline or azithromycin, but doxycycline is avoided in pregnancy. She therefore needs ceftriaxone for gonorrhea plus azithromycin for chlamydia.

Why the answer is ceftriaxone plus azithromycin

This question combines two separate infections—gonorrhea and chlamydia—in one pregnant patient, so the treatment plan must address both organisms while respecting pregnancy safety. The correct regimen is intramuscular ceftriaxone for gonorrhea plus oral azithromycin for chlamydia.

Gonorrhea in pregnancy is treated with a parenteral cephalosporin because Neisseria gonorrhoeae has developed widespread resistance to penicillins, tetracyclines, and fluoroquinolones. The randomized trial by Ramus et al. evaluated ceftriaxone 125 mg IM against oral cefixime in pregnant women with endocervical gonorrhea and found that both regimens were effective, supporting ceftriaxone as a first-line option ^[1]. An earlier trial by Cavenee et al. similarly demonstrated that ceftriaxone 250 mg IM was effective for gonorrhea in pregnancy, while amoxicillin plus probenecid was less reliable ^[2]. Therefore, the gonorrhea component of this patient’s treatment must be ceftriaxone, not an oral agent alone.

For chlamydia, the standard nonpregnant options are doxycycline or azithromycin. However, doxycycline is contraindicated in pregnancy because tetracyclines can cause fetal tooth discoloration and impaired bone growth. Azithromycin is the preferred alternative. A meta-analysis of eight randomized controlled trials involving 587 pregnant women with documented Chlamydia trachomatis infection found that single-dose azithromycin was at least as effective as erythromycin and was better tolerated, with fewer gastrointestinal side effects and higher compliance ^[3]. A separate RCT by Adair et al. also reported that azithromycin 1 g orally as a single dose produced high cure rates with significantly fewer side effects than a 7-day course of erythromycin in pregnant women ^[4].

Watch out! Option 1 (ceftriaxone plus doxycycline) would treat both infections correctly in a nonpregnant adult, but doxycycline is unsafe in pregnancy. Option 3 (azithromycin alone) and option 4 (doxycycline alone) fail because neither azithromycin nor doxycycline alone reliably eradicates gonorrhea—gonorrhea requires ceftriaxone.

Key point! When a pregnant patient has coexisting gonorrhea and chlamydia, the nurse should expect dual therapy: ceftriaxone for gonorrhea and azithromycin for chlamydia. This pairing avoids doxycycline while still covering both pathogens effectively.

Infection	Preferred treatment in pregnancy	Why this choice
Gonorrhea (Neisseria gonorrhoeae)	Ceftriaxone IM	High cure rates in pregnancy; oral cefixime is an alternative but IM ceftriaxone is standard [1][2]
Chlamydia (Chlamydia trachomatis)	Azithromycin oral, single dose	Effective and better tolerated than erythromycin; doxycycline is contraindicated in pregnancy [3][4]

The partner’s syphilis is managed separately and does not change the gonorrhea/chlamydia regimen. Because she is 10 weeks pregnant, the nurse should anticipate an order for ceftriaxone intramuscularly plus oral azithromycin.