What is the alternative treatment for gonorrhea in a patient allergic to cephalosporin (a type of antibiotic)?

From the Guidelines

For patients allergic to cephalosporins, azithromycin 2 g orally in a single dose is a recommended alternative treatment for gonorrhea. This recommendation is based on the most recent and highest quality evidence available, which emphasizes the importance of effective treatment to prevent complications and the emergence of resistance 1. When ceftriaxone cannot be used due to severe allergy, azithromycin 2 g orally as a single dose is an alternative option.

Key Considerations

• The patient should return 1 week after treatment for a test-of-cure at the infected anatomic site, ideally performed with culture or a NAAT for N. gonorrhoeae if culture is not readily available 1.
• If the NAAT is positive, every effort should be made to perform a confirmatory culture, and all positive cultures for test-of-cure should undergo phenotypic antimicrobial susceptibility testing 1.
• Patients who experience treatment failure after treatment with alternative regimens should be treated with ceftriaxone 250 mg as a single intramuscular dose and azithromycin 2 g orally as a single dose and should receive infectious disease consultation 1.

Additional Recommendations

• Treatment should be accompanied by testing for other sexually transmitted infections, particularly chlamydia, which often co-occurs with gonorrhea.
• Partners from the previous 60 days should also be notified and treated to prevent further transmission.
• Follow-up testing to confirm cure is recommended 1-2 weeks after treatment completion, especially when using alternative regimens.

From the Research

Alternative Treatments for Gonorrhea in Patients Allergic to Cephalosporin

• For patients allergic to cephalosporin, alternative treatments for gonorrhea have been explored due to the emergence of resistance and the need for backup options 2.
• Studies have investigated the efficacy of gentamicin plus azithromycin and gemifloxacin plus azithromycin as potential treatments 2.
• The combination of gentamicin and azithromycin has shown high efficacy in treating urogenital gonorrhea, with a microbiological cure rate of 100% in one study 2.
• However, gentamicin alone has been found to be inadequate in eradicating Neisseria gonorrhoeae from the pharynx, with a cure rate of only 20% in one study 3.
• Another study compared gentamicin to ceftriaxone for the treatment of gonorrhea and found that gentamicin was not non-inferior to ceftriaxone, especially for pharyngeal and rectal infections 4.
• A systematic review and meta-analysis found that gentamicin does not meet current CDC criteria for recommended treatment of gonorrhea, with a pooled percentage of negative culture after single-dose treatment of 91.5% 5.
• Azithromycin alone is not recommended as monotherapy due to concerns over the emergence of resistance, but it can be used as part of dual therapy with a cephalosporin or as an alternative in patients with cephalosporin allergy 6.

Treatment Options

• Gentamicin plus azithromycin may be a useful alternative option for patients who cannot be treated with cephalosporin antimicrobials 2.
• Gemifloxacin plus azithromycin is another potential treatment option, with high efficacy in treating urogenital gonorrhea 2.
• However, the use of gentamicin alone is not recommended due to its poor efficacy in eradicating Neisseria gonorrhoeae from the pharynx 3.