What is the treatment for co-infection of Chlamydia (Chlamydia trachomatis) and Gonorrhea (Neisseria gonorrhoeae) in a patient with a Cephalosporin allergy?

From the Guidelines

For patients with a cephalosporin allergy who need treatment for both chlamydia and gonorrhea, the recommended approach is a dual therapy regimen, with gentamicin 240 mg intramuscular injection as a single dose plus azithromycin 2 grams orally as a single dose for gonorrhea, and doxycycline 100 mg orally twice daily for 7 days for chlamydia, as suggested by the European Association of Urology guidelines 1.

Treatment Approach

The treatment of chlamydia and gonorrhea in patients with a cephalosporin allergy requires careful consideration of alternative antimicrobial regimens.

• For chlamydia, the preferred treatment is doxycycline 100 mg orally twice daily for 7 days, as outlined in the guidelines 1.
• For gonorrhea, in cases of cephalosporin allergy, gentamicin 240 mg intramuscular injection as a single dose plus azithromycin 2 grams orally as a single dose is recommended, according to the European Association of Urology guidelines 1.

Alternative Regimens

If gentamicin is not available or suitable, alternative regimens for gonorrhea include:

• Gemifloxacin 320 mg orally as a single dose plus azithromycin 2 grams orally as a single dose
• Spectinomycin 2 grams intramuscularly as a single dose, though availability varies by region
• Fosfomycin trometamol 3 grams orally on days 1,3, and 5 It is essential to note that these alternative regimens may be less effective than cephalosporin-based treatments, so follow-up testing to confirm cure is crucial, typically 2-3 weeks after treatment completion 1.

Additional Considerations

• Sexual partners should also be treated to prevent reinfection.
• Patients should abstain from sexual activity until both they and their partners have completed treatment and are symptom-free. The dual therapy approach is necessary because these infections often occur together, and treating both simultaneously helps prevent complications like pelvic inflammatory disease, infertility, and increased HIV transmission risk 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. Uncomplicated urethral, endocervical, or rectal infection in adults caused by Chlamydia trachomatis: 100 mg, by mouth, twice a day for 7 days. Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae.

For patients with cephalosporin allergy, the recommended treatment for chlamydia and gonorrhea is:

• Doxycycline 100 mg, by mouth, twice a day for 7 days 2
• Azithromycin is also an option, but the dosage is not specified in the label for the treatment of gonorrhea and chlamydia in adults with cephalosporin allergy 3 Key points:
• Doxycycline is a recommended treatment for both chlamydia and gonorrhea.
• Azithromycin may be used to treat chlamydia, but its use for gonorrhea is not recommended due to resistance concerns.

From the Research

Treatment Options for Chlamydia and Gonorrhea with Cephalosporin Allergy

• For patients with cephalosporin allergy, alternative treatment options for gonorrhea are limited 4, 5.
• A study found that gentamicin plus azithromycin and gemifloxacin plus azithromycin were highly effective for treating urogenital gonorrhea, with microbiological cure rates of 100% and 99.5%, respectively 4.
• However, these regimens may not be suitable for all patients, and gastrointestinal adverse events were common in both arms 4.
• For chlamydia treatment, doxycycline has been shown to be more effective than azithromycin for rectal infections, with cure rates of 95.5% and 78.5%, respectively 6, 7.
• A 7-day course of doxycycline was found to be superior to single-dose azithromycin for treating rectal chlamydia infection among men who have sex with men 7.

Recommended Treatment Regimens

• For patients with cephalosporin allergy and gonorrhea, gentamicin plus azithromycin or gemifloxacin plus azithromycin may be considered as alternative treatment options 4.
• For chlamydia treatment, doxycycline (100 mg twice daily for 7 days) is recommended, especially for rectal infections 6, 7.
• If coinfection with chlamydia has not been excluded, cotreatment with doxycycline (100 mg twice daily for 7 days) may be added to the gonorrhea treatment regimen 8, 5.