# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629818  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

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?

## 보기

1. Ceftriaxone intramuscularly plus oral doxycycline
2. Ceftriaxone intramuscularly plus oral azithromycin **✔ 정답**
3. Oral azithromycin alone, to cover both of the infections
4. Oral doxycycline alone, to cover both of the infections

**정답: 2**

## 해설

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.

## 심화 해설

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.References (research sources)

- [1]A randomized trial that compared oral cefixime and intramuscular ceftriaxone for the treatment of gonorrhea in pregnancy.RCT/clinical trialRamus RM, Sheffield JS, Mayfield JA, Wendel GD (2001) · DOI: 10.1067/mob.2001.117662

- [2]Treatment of gonorrhea in pregnancy.Research articleCavenee MR, Farris JR, Spalding TR, Barnes DL, Castaneda YS, Wendel GD (1993)

- [3]Single-dose azithromycin versus erythromycin or amoxicillin for Chlamydia trachomatis infection during pregnancy: a meta-analysis of randomised controlled trials.Meta-analysis/systematic reviewPitsouni E, Iavazzo C, Athanasiou S, Falagas ME (2007) · DOI: 10.1016/j.ijantimicag.2007.04.015

- [4]Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin.RCT/clinical trialAdair CD, Gunter M, Stovall TG, McElroy G, Veille JC, Ernest JM (1998) · DOI: 10.1016/s0029-7844(97)00586-3

## 임상 시나리오

Pregnancy-Safe Treatment for Gonorrhea and ChlamydiaDual infection management in a pregnant patient
For gonorrhea in pregnancy, use intramuscular ceftriaxone as first-line therapy because Neisseria gonorrhoeae has widespread resistance to penicillins, tetracyclines, and fluoroquinolones.

For chlamydia in pregnancy, use oral azithromycin as the preferred agent. Doxycycline is contraindicated because tetracyclines can cause fetal tooth discoloration and impaired bone growth.

CautionDo not treat gonorrhea with oral azithromycin alone. Parenteral ceftriaxone is required for reliable gonorrhea coverage, and azithromycin is added only for chlamydia.

## 핵심 개념

- **ceftriaxone** — Parenteral third-generation cephalosporin used as first-line treatment for gonorrhea, including in pregnancy.
- **azithromycin** — Macrolide antibiotic used as preferred treatment for chlamydia in pregnancy when doxycycline is contraindicated.
- **doxycycline** — Tetracycline antibiotic effective for chlamydia but contraindicated in pregnancy due to fetal tooth discoloration and impaired bone growth.
- **gonorrhea** — Sexually transmitted infection caused by Neisseria gonorrhoeae, treated with IM ceftriaxone due to antimicrobial resistance.
- **chlamydia** — Sexually transmitted infection caused by Chlamydia trachomatis, treated with azithromycin or doxycycline in nonpregnant patients.

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