From the Guidelines
The recommended treatment for Neisseria gonorrhoeae infection is a dual therapy approach consisting of ceftriaxone 250 mg as a single intramuscular injection plus azithromycin 1 gram orally as a single dose, as this combination is necessary due to increasing antibiotic resistance patterns, as noted in the 2012 CDC guidelines 1.
Key Considerations
- The treatment approach targets different bacterial mechanisms, with ceftriaxone disrupting cell wall synthesis and azithromycin inhibiting protein synthesis, providing more effective clearance and helping prevent the development of resistance.
- Alternative regimens for patients with severe penicillin allergy include gentamicin 240 mg intramuscularly plus azithromycin 2 grams orally as single doses, as recommended by the 2024 Lancet Infectious Diseases guidelines 1.
- All sexual partners from the previous 60 days should be notified, tested, and treated empirically even if asymptomatic.
- Patients should abstain from sexual activity until they and their partners have completed treatment and symptoms have resolved, typically about 7 days after treatment.
- Follow-up testing is recommended 3 months after treatment due to the risk of reinfection.
Treatment Failure
- In cases of suspected ceftriaxone treatment failure, the 2021 US Centers for Disease Control and Prevention treatment guidelines recommend obtaining a specimen for culture and antimicrobial susceptibility testing, reporting the case to local public health officials within 24 h, consulting an expert in either infectious or sexually transmitted diseases, and considering treatment with one dose of intramuscular gentamicin 240 mg and one dose of azithromycin 2 g orally, as noted in the 2024 Lancet Infectious Diseases guidelines 1.
- The European guidelines recommend intramuscular ceftriaxone 1 g in combination with one dose of azithromycin 2 g orally as a first-line regimen, with alternatives including intramuscular spectinomycin 2 g with azithromycin 2 g orally, intramuscular gentamicin 240 mg with one dose of azithromycin 2 g orally, or intramuscular ertapenem 1 g for 3 days.
From the FDA Drug Label
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).
1 Adults The recommended dose of cefixime is 400 mg daily. This may be given as a 400 mg capsule daily. For the treatment of uncomplicated cervical/urethral gonococcal infections, a single oral dose of 400 mg is recommended.
- Treatment Guideline: The recommended treatment for Neisseria gonorrhoeae infection is a single oral dose of 400 mg cefixime 2.
- Alternative Treatment: Doxycycline is an alternative drug in the treatment of uncomplicated gonorrhea caused by Neisseria gonorrhoeae 3.
From the Research
Treatment Guidelines for Neisseria gonorrhoeae
The recommended treatment for Neisseria gonorrhoeae infection is as follows:
- A single 500 mg intramuscular (IM) dose of ceftriaxone for treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 4, 5.
- If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 4, 5.
Antimicrobial Resistance
Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern 5, 6, 7.
- Decreased susceptibility of N. gonorrhoeae to third-generation cephalosporins, especially cefixime, has emerged worldwide 6.
- Resistance to ciprofloxacin and penicillin is also high 6, 8.
- Dual treatment with ceftriaxone or cefixime and azithromycin or doxycycline is currently recommended for gonorrhea in some regions, but reduced susceptibility and resistance to these antibiotics are increasing 5, 8, 7.
Surveillance and Future Treatment
Continued surveillance of gonococcal antimicrobial resistance is essential to ensuring the efficacy of recommended regimens 4, 5, 6.
- Novel affordable antimicrobials for monotherapy or inclusion in new dual treatment regimens are needed to address the emerging resistance 7.
- Rapid phenotypic AMR tests and/or genetic point of care AMR tests, including detection of gonococci, may improve the management and public health control of gonorrhea and AMR in the future 7.