What is the recommended treatment for gonorrhea?

Treatment of Gonorrhea

The recommended treatment for uncomplicated gonorrhea is combination therapy with a single intramuscular dose of ceftriaxone 250 mg plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days, with azithromycin being the preferred second antimicrobial. 1

First-Line Treatment Regimens

Uncomplicated Urogenital, Anorectal, and Pharyngeal Gonorrhea

• Recommended regimen:
  • Ceftriaxone 250 mg IM in a single dose
  • PLUS
  • Azithromycin 1 g orally in a single dose (preferred) OR
  • Doxycycline 100 mg orally twice daily for 7 days

Azithromycin is preferred over doxycycline as the second antimicrobial due to:

1. Convenience and better compliance with single-dose therapy
2. Substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 1

Alternative Regimens

When ceftriaxone cannot be used, the following alternatives are recommended:

If ceftriaxone is not available:

• Cefixime 400 mg orally in a single dose
• PLUS
• Azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally twice daily for 7 days
• PLUS
• Test-of-cure in 1 week

If patient has severe cephalosporin allergy:

• Azithromycin 2 g orally in a single dose
• PLUS
• Test-of-cure in 1 week

Important Clinical Considerations

Treatment Failure Management

If treatment failure occurs with the recommended combination therapy:

1. Culture relevant clinical specimens
2. Perform antimicrobial susceptibility testing of N. gonorrhoeae isolates
3. Consult an infectious disease specialist, STD/HIV Prevention Training Center, or CDC
4. Report the case to CDC through local or state health department within 24 hours
5. Conduct a test-of-cure 1 week after re-treatment
6. Ensure evaluation and treatment of sex partners from the preceding 60 days 1

Test-of-Cure Requirements

• Not routinely recommended for patients treated with the recommended regimens
• Required for:
  • Patients treated with alternative regimens
  • Persistent symptoms after treatment
  • Suspected treatment failure

Partner Management

• All sex partners from the previous 60 days should be referred for evaluation and treatment
• If last sexual contact was >60 days before diagnosis, the most recent partner should be treated
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1

Special Populations

Pregnancy

• Pregnant women should not receive quinolones or tetracyclines
• Recommended treatment: ceftriaxone 250 mg IM plus azithromycin 1 g orally
• For cephalosporin allergy: consult specialist 1

HIV Infection

• Patients with HIV should receive the same treatment regimen as HIV-negative patients 1

Antimicrobial Resistance Considerations

The CDC no longer recommends cefixime as a first-line regimen due to concerns about emerging resistance 1. The dual therapy approach using two antimicrobials with different mechanisms of action is designed to:

1. Improve treatment efficacy
2. Potentially delay emergence and spread of resistance to cephalosporins
3. Treat possible co-infection with Chlamydia trachomatis 1

Complications and Follow-up

Patients with uncomplicated gonorrhea who are treated with the recommended regimens do not need routine follow-up testing for cure. However, due to high reinfection rates, retesting is recommended 3 months after treatment 1.

Untreated gonorrhea can lead to serious complications including pelvic inflammatory disease, infertility, and increased risk of HIV transmission, highlighting the importance of prompt and effective treatment 2.