From the Guidelines
The recommended treatment for gonorrhea is a dual therapy approach consisting of a single intramuscular injection of ceftriaxone 250 mg, combined with oral azithromycin 1 gram taken as a one-time dose. This combination is necessary because gonorrhea bacteria (Neisseria gonorrhoeae) have developed resistance to many antibiotics over time, as evident from the increasing minimum inhibitory concentrations (MICs) of cefixime 1. Ceftriaxone targets the bacterial cell wall while azithromycin works by inhibiting bacterial protein synthesis, providing complementary mechanisms of action. The use of azithromycin as the second antimicrobial is preferred to doxycycline because of the convenience and compliance advantages of single-dose therapy and the substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin among GISP isolates 1.
Key considerations for treatment include:
- The dose of ceftriaxone should not exceed 250 mg, as clinical data to support higher doses are not available 1
- Cefixime is no longer recommended as a first-line treatment due to increasing resistance and declining effectiveness 1
- Patients should abstain from sexual activity for 7 days to prevent transmission and should ensure all recent sexual partners are notified and treated to prevent reinfection
- A follow-up test of cure is recommended 1-2 weeks after completing treatment, especially in cases of pharyngeal infection which can be more difficult to eradicate
- People with gonorrhea should also be tested for other sexually transmitted infections, particularly chlamydia, syphilis, and HIV, as co-infections are common
It is essential to note that the emergence of resistance to cephalosporins, including ceftriaxone, is a significant concern, and maintaining its effectiveness is critical 1. Therefore, combination therapy with azithromycin is recommended to improve treatment efficacy and potentially delay the emergence and spread of resistance to cephalosporins.
From the FDA Drug Label
For the treatment of uncomplicated gonococcal infections, a single intramuscular dose of 250 mg is recommended. The recommended treatment for gonorrhea is a single intramuscular dose of 250 mg of ceftriaxone.
- Key points:
- The dose is administered intramuscularly.
- The treatment is for uncomplicated gonococcal infections.
- No dosage adjustment is necessary for patients with impairment of renal or hepatic function 2
From the Research
Treatment Options for Gonorrhea
- The recommended treatment for gonorrhea is a single 500 mg intramuscular dose of ceftriaxone 3.
- Dual therapy with ceftriaxone and azithromycin was previously recommended, but due to increasing concern for antimicrobial stewardship and the potential impact of dual therapy on commensal organisms and concurrent pathogens, the recommendation has been updated to a single dose of ceftriaxone 3.
- If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 3.
- For pregnant women, the recommended treatment is the same as for non-pregnant women, with a single 500 mg intramuscular dose of ceftriaxone 4, 3.
Alternative Treatment Options
- A single dose of cefixime (400 or 800 mg) given orally has been shown to be as effective as ceftriaxone in the treatment of uncomplicated gonorrhea 5.
- Azithromycin may be used as an alternative treatment option for patients with previous allergic reactions to penicillin, but its use should be limited due to the likelihood of antimicrobial resistance 6.
Follow-up and Retesting
- A test-of-cure is not needed for individuals diagnosed with uncomplicated urogenital or rectal gonorrhea who are treated with the recommended or alternative regimens 4.
- Patients should be retested 3 months after treatment to check for reinfection 4, 6, 7.
- Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 4.