From the Guidelines
For patients with gonorrhea who have a cephalosporin allergy, the recommended treatment is gentamicin 240 mg intramuscularly as a single dose plus azithromycin 2 g orally as a single dose, as suggested by the European Association of Urology guidelines 1. This regimen is effective against Neisseria gonorrhoeae, the bacterium that causes gonorrhea. Before proceeding with treatment, it's essential to confirm the nature of the cephalosporin allergy, as true allergies are relatively rare and some patients may have had non-allergic side effects misclassified as allergies. If the allergy is severe or anaphylactic, consultation with an infectious disease specialist is advisable. Some key points to consider when treating gonorrhea in patients with cephalosporin allergy include:
- The use of gentamicin plus azithromycin as an alternative regimen, as supported by recent guidelines 1
- The importance of follow-up testing to confirm cure, typically 1-2 weeks after treatment
- The need to treat partners simultaneously to prevent reinfection
- The potential for antibiotic resistance, which may require susceptibility testing in cases of treatment failure, as discussed in a recent review 2 Alternative options, such as spectinomycin 2 grams intramuscularly as a single dose, or fosfomycin trometamol 3 g orally on days 1, 3, and 5, may be considered, though availability and efficacy may vary 1.
From the FDA Drug Label
Uncomplicated gonococcal infections in adults (except anorectal infections in men):100 mg, by mouth, twice a day for 7 days. As an alternate single visit dose, administer 300 mg stat followed in one hour by a second 300 mg dose. Syphilis–early: Patients who are allergic to penicillin should be treated with doxycycline 100 mg, by mouth, twice a day for 2 weeks Acute epididymo-orchitis caused by N. gonorrhoeae: 100 mg, by mouth, twice a day for at least 10 days.
The recommended treatment for gonorrhea with a cephalosporin allergy is doxycycline 100 mg, by mouth, twice a day for 7 days 3.
- Doxycycline is an alternative for patients allergic to penicillin and cephalosporins.
- The dosage may vary depending on the specific condition being treated, such as syphilis or epididymo-orchitis.
- Azithromycin may also be considered as an alternative treatment for gonorrhea, but its effectiveness in this context is not explicitly stated in the provided drug labels 4.
From the Research
Treatment Options for Gonorrhea with Cephalosporin Allergy
- For patients with cephalosporin allergy, alternative treatment options are limited 5, 6.
- Gentamicin plus azithromycin is a potential alternative treatment regimen, with studies showing high efficacy for urogenital gonorrhea 5, 7.
- However, gentamicin alone may not be sufficient to eradicate Neisseria gonorrhoeae from the pharynx, with one study showing poor efficacy 8.
- A systematic review and meta-analysis found that gentamicin does not meet current CDC criteria for recommended treatment of gonorrhea, but may be a useful alternative agent if cephalosporin resistance emerges 9.
Efficacy of Gentamicin Plus Azithromycin
- A randomized controlled trial found that gentamicin 240 mg plus azithromycin 2 g was non-inferior to ceftriaxone 500 mg plus azithromycin 2 g for treatment of rectal and pharyngeal gonorrhea 7.
- Another study found that gentamicin plus azithromycin was highly effective for treatment of urogenital gonorrhea, with microbiological cure achieved by 100% of participants 5.
Considerations for Treatment
- Gastrointestinal adverse events were common in both gentamicin plus azithromycin and ceftriaxone plus azithromycin arms 5, 7.
- The CDC recommends 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites, with cotreatment with doxycycline if coinfection with chlamydia has not been excluded 6.
- For persons with cephalosporin allergies, few alternative therapies exist, and there are no recommended alternative therapies for N gonorrhoeae infection of the throat 6.