What is the recommended treatment plan for chlamydia and gonorrhea?

Treatment Plan for Chlamydia and Gonorrhea

For uncomplicated chlamydial and gonococcal infections, the recommended treatment is ceftriaxone 500 mg IM as a single dose for gonorrhea, plus doxycycline 100 mg orally twice daily for 7 days for chlamydia. This dual therapy approach is essential due to the high rate of coinfection between these two STIs.

Chlamydia Treatment

First-line Options:

• Doxycycline 100 mg orally twice daily for 7 days (preferred)
• Azithromycin 1 g orally in a single dose (alternative)

Alternative Options (if first-line cannot be used):

• Erythromycin base 500 mg orally four times daily for 7 days
• Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days
• Ofloxacin 300 mg orally twice daily for 7 days
• Levofloxacin 500 mg orally once daily for 7 days

While both azithromycin and doxycycline have shown similar efficacy (97-98% cure rates) 1, recent evidence suggests doxycycline may be more effective, particularly for rectal infections. Doxycycline is also less expensive than azithromycin 1.

Gonorrhea Treatment

Recommended Regimen:

• Ceftriaxone 500 mg IM in a single dose (for persons <150 kg) 2

Alternative Regimens (if ceftriaxone unavailable):

• Cefixime 400 mg orally in a single dose
• Spectinomycin 2 g IM in a single dose (for patients with cephalosporin allergy)

Dual Therapy Considerations

Patients with gonorrhea frequently have concurrent chlamydial infection (10-30% coinfection rate) 1. Therefore, presumptive treatment for chlamydia is recommended when treating gonorrhea. This dual approach helps prevent complications and reduce transmission.

Special Populations

Pregnant Women:

• Avoid doxycycline and fluoroquinolones
• For chlamydia: Azithromycin 1 g orally in a single dose
• For gonorrhea: Ceftriaxone 500 mg IM in a single dose
• Test of cure recommended 4 weeks after treatment 2

HIV-Infected Patients:

• Same treatment regimens as HIV-negative patients 1

Patients with Pharyngeal Gonorrhea:

• Ceftriaxone 500 mg IM in a single dose (pharyngeal infections are more difficult to eradicate) 1

Management of Sex Partners

• All sex partners from the previous 60 days should be evaluated, tested, and treated 1
• If last sexual contact was >60 days before diagnosis, the most recent partner should be treated
• Patients and partners should abstain from sexual intercourse until:
  • 7 days after single-dose therapy OR
  • Completion of 7-day regimen AND
  • Resolution of symptoms in both patient and partners 1

Follow-Up Recommendations

• No test of cure is needed for patients treated with recommended regimens unless symptoms persist
• Retesting is recommended approximately 3 months after treatment due to high reinfection rates 1
• Patients should be retested whenever they seek care within 12 months after initial treatment 1

Clinical Pearls and Pitfalls

• Medication adherence: Consider directly observed therapy with azithromycin for patients with questionable compliance 1
• Antimicrobial resistance: Be aware of increasing quinolone resistance in gonorrhea, particularly in certain geographic areas 1
• Persistent symptoms: If symptoms persist after treatment, evaluate for reinfection, treatment failure, or other causes
• Extragenital infections: Don't forget to test and treat rectal and pharyngeal infections, which are often asymptomatic 2
• Reinfection risk: Counsel patients about high reinfection risk and importance of partner treatment 3

This evidence-based approach to treating chlamydia and gonorrhea prioritizes regimens with the highest efficacy and considers patient-specific factors to maximize treatment success and minimize complications.