Persistent urethral Neisseria gonorrhoeae detection by NAAT despite ceftriaxone and spectinomycin treatment with subsequent clearance following short-course cefixime therapy: a case report

Ceftriaxone is recommended as first-line therapy for uncomplicated gonorrhea worldwide. Although highly effective, persistent nucleic acid amplification test (NAAT) positivity after recommended therapy has been reported. A man in his 30s (Asian) presented with purulent urethral discharge. NAAT confirmed Neisseria gonorrhoeae . He received intravenous ceftriaxone 1 g. Despite clinical resolution, a test-of-cure NAAT performed 21 days later remained positive. Intramuscular spectinomycin 2 g was subsequently administered; however, NAAT remained positive 25 days after spectinomycin administration in the absence of sexual re-exposure. Oral cefixime (200 mg once daily for 3 days) was then prescribed. A follow-up NAAT performed 19 days after completion of cefixime therapy was negative. The patient remained asymptomatic throughout follow-up. This case highlights the challenges of interpreting persistent NAAT positivity following recommended therapy for uncomplicated gonorrhoea. In the absence of culture and antimicrobial susceptibility testing, the clinical significance of prolonged NAAT positivity remains uncertain, and true treatment failure cannot be distinguished from prolonged persistence of nonviable bacterial DNA or possible reinfection. This report underscores the potential value of test-of-cure in selected clinical situations and the need for cautious interpretation of post-treatment NAAT results.