What is the treatment for Neisseria gonorrhoeae (gonorrhea) infection?

From the Guidelines

Gonorrhea should be treated with a dual therapy approach, combining a single intramuscular injection of ceftriaxone 250mg with oral azithromycin 1g as a single dose, as this is the most reliably effective treatment for uncomplicated gonorrhea, according to the CDC's current recommendations 1. The use of ceftriaxone in combination with azithromycin is preferred due to the rising rates of antibiotic-resistant gonorrhea and the potential for cefixime to become less effective in treating urogenital gonorrhea 1.

• Key points to consider in the treatment of gonorrhea include:
  • The importance of completing the full course of antibiotics, even if symptoms improve before finishing treatment
  • The need for sexual partners from the past 60 days to be tested and treated to prevent reinfection
  • The recommendation for patients to abstain from sexual activity until both they and their partners have completed treatment and are symptom-free, typically for 7 days after finishing antibiotics
  • The importance of follow-up testing 1-2 weeks after treatment completion to confirm cure, especially given the rising rates of antibiotic-resistant gonorrhea The dual therapy approach targets the Neisseria gonorrhoeae bacteria from multiple angles, reducing the likelihood of treatment failure due to resistance mechanisms that have developed against single antibiotics 1.
• Alternative regimens, such as gentamicin 240mg intramuscularly plus azithromycin 2g orally in a single dose, may be considered for patients with severe penicillin allergies, but the use of ceftriaxone and azithromycin is generally preferred due to its high efficacy and convenience 1. It is essential to note that the CDC no longer recommends the routine use of cefixime as a first-line regimen for treatment of gonorrhea in the United States, due to the rising rates of antibiotic-resistant gonorrhea and the potential for cefixime to become less effective in treating urogenital gonorrhea 1.

From the FDA Drug Label

1. 5 Uncomplicated Gonorrhea (cervical/urethral) Cefixime for oral suspension and cefixime capsule is indicated in the treatment of adults and pediatric patients six months of age or older with uncomplicated gonorrhea (cervical/urethral) caused by susceptible isolates of Neisseria gonorrhoeae(penicillinase-and non-penicillinase-producing isolates). Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae.

Treatment for Gonorrhea:

• Cefixime is indicated for the treatment of uncomplicated gonorrhea (cervical/urethral) caused by susceptible isolates of Neisseria gonorrhoeae 2.
• Azithromycin is also indicated for the treatment of urethritis and cervicitis due to Neisseria gonorrhoeae 3.
• The recommended dose of cefixime for the treatment of uncomplicated gonorrhea is a single oral dose of 400 mg 2.
• Azithromycin dosage is not specified in the label for the treatment of gonorrhea.

From the Research

Treatment Options for Gonorrhea

• The current recommended treatment for uncomplicated gonorrhea is a single 500 mg intramuscular dose of ceftriaxone, as stated in the 2020 CDC guidelines 4.
• If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 4, 5.
• Dual therapy with ceftriaxone and azithromycin was previously recommended, but due to increasing resistance to azithromycin, this recommendation has been reevaluated 6, 7.

Antimicrobial Resistance

• Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern 7, 5.
• The proportion of isolates with an elevated MIC to azithromycin has increased rapidly, with nearly 5% in 2018, according to the Gonococcal Isolate Surveillance Project (GISP) 5.
• Ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL) 5.

Alternative Therapies

• Few alternative therapies exist for persons with cephalosporin allergies, and there are no recommended alternative therapies for N gonorrhoeae infection of the throat 5.
• Strategies being pursued to combat antimicrobial-resistant N. gonorrhoeae include developing molecular assays to predict resistance, utilizing higher doses of ceftriaxone, repurposing older antibiotics, and developing newer agents 7.