What is the first-line treatment for a suspected Sexually Transmitted Infection (STI) to cover both Neisseria gonorrhoeae (gonorrhea) and Chlamydia trachomatis (chlamydia)?

From the Guidelines

The first-line treatment for suspected dual infection with Neisseria gonorrhoeae and Chlamydia trachomatis is a combination of ceftriaxone 250 mg as a single intramuscular injection plus azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of combination therapy to ensure effective treatment of both gonorrhea and chlamydia, as well as to address the growing concern of antimicrobial resistance 1. The use of ceftriaxone is preferred due to its ability to effectively treat gonorrhea, while azithromycin or doxycycline is added to cover chlamydia, given the high frequency of co-infection between these two pathogens. Key points to consider in the treatment approach include:

• The choice between azithromycin and doxycycline may depend on patient tolerance, potential side effects, and local resistance patterns.
• Patients should be advised to abstain from sexual activity for 7 days after completion of treatment and until all partners have been treated.
• Follow-up testing is crucial, particularly in high-risk individuals, to confirm cure and prevent further transmission.
• Treatment should be initiated empirically when infection is suspected, without waiting for test results, to prevent complications and transmission. It's also important to note that while older guidelines may suggest different treatment regimens, such as those outlined in studies from 2002 1 and 1993 1, the most recent guidance from 2012 1 takes precedence due to its recency and the evolving nature of antimicrobial resistance.

From the FDA Drug Label

Uncomplicated Gonorrhea (cervical/urethral and rectal) caused by Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase-producing strains of Neisseria gonorrhoeae. Ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis. Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae.

The first-line treatment for a suspected STI to cover both Neisseria gonorrhoeae (gonorrhea) and Chlamydia trachomatis (chlamydia) is a combination of ceftriaxone (to cover gonorrhea) and azithromycin (to cover chlamydia) 2 3.

• Ceftriaxone is effective against Neisseria gonorrhoeae, but has no activity against Chlamydia trachomatis.
• Azithromycin is effective against Chlamydia trachomatis and can be used in combination with ceftriaxone to provide coverage for both pathogens.

From the Research

First-Line Treatment for Suspected STI

The first-line treatment for a suspected Sexually Transmitted Infection (STI) to cover both Neisseria gonorrhoeae (gonorrhea) and Chlamydia trachomatis (chlamydia) is as follows:

• For uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, a single 500 mg intramuscular (IM) dose of ceftriaxone is recommended 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.
• Previously, dual therapy with ceftriaxone and azithromycin was recommended, but due to increasing concern for antimicrobial stewardship and the potential impact of dual therapy on commensal organisms and concurrent pathogens, this recommendation has been reevaluated 4, 6.

Rationale for Treatment

The recommended treatment is based on the following rationale:

• Ceftriaxone is effective against gonorrhea, and its minimal inhibitory concentrations (MICs) have remained stable in the United States 5.
• Doxycycline is effective against chlamydia, and its use as a concurrent treatment helps to prevent complications and transmission 4, 5.
• Azithromycin resistance has been increasing, making it less effective as a first-line treatment for gonorrhea 6, 5.

Alternative Treatments

Alternative treatments may be considered in certain cases, such as:

• For persons with cephalosporin allergies, few alternative therapies exist for persons with gonorrhea 5.
• For chlamydia, azithromycin may be considered as an alternative treatment, but a test-of-cure is recommended if treated with azithromycin 7.