What is the recommended treatment regimen for gonorrhea?

Recommended Treatment Regimen for Gonorrhea

For uncomplicated gonorrhea infections, the recommended treatment is a single intramuscular dose of ceftriaxone 250 mg plus 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

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. Higher prevalence of gonococcal resistance to tetracycline compared to azithromycin 1

Alternative Regimens

If Ceftriaxone is Unavailable:

• 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

For Patients with Severe Cephalosporin Allergy:

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

Rationale for Current Recommendations

The 2012 CDC guidelines updated previous recommendations due to:

1. Rising cefixime MICs (minimum inhibitory concentrations) indicating decreased effectiveness
2. Concern that continued cefixime use might hasten development of resistance to ceftriaxone
3. Need to maintain effectiveness of ceftriaxone as the last highly effective antimicrobial for gonorrhea 1

Dual therapy with two antimicrobials having different mechanisms of action is recommended to:

• Improve treatment efficacy
• Potentially delay emergence and spread of resistance to cephalosporins 1

Special Considerations

Treatment Failure Management

If gonorrhea persists after recommended treatment:

1. Culture relevant clinical specimens
2. Perform antimicrobial susceptibility testing
3. Consult an infectious disease specialist or CDC
4. Report the case to CDC through local/state health department within 24 hours
5. Conduct test-of-cure 1 week after re-treatment
6. Evaluate and treat sex partners from preceding 60 days 1

Pregnancy

• Pregnant women should not receive quinolones or tetracyclines
• Recommended treatment: Ceftriaxone 250 mg IM in a single dose 1

Follow-Up

• Test of cure is not needed for patients treated with recommended regimens
• Patients with persistent symptoms should be evaluated by culture for N. gonorrhoeae
• Consider retesting all patients 3 months after treatment due to high reinfection rates 1

Partner Management

• All sex partners from the previous 60 days should be evaluated and treated
• If last sexual contact was >60 days before symptoms/diagnosis, treat most recent partner
• Patients should avoid sexual intercourse until therapy is completed and symptoms resolve 1

Antimicrobial Resistance Concerns

The evolution of treatment recommendations reflects the ongoing challenge of antimicrobial resistance in N. gonorrhoeae:

• Penicillins, tetracyclines, and macrolides are no longer adequately effective 1
• Fluoroquinolones (ciprofloxacin, ofloxacin) were previously recommended but are no longer first-line due to resistance 1
• Ceftriaxone remains the most effective antimicrobial, but vigilance for resistance is essential 1

The current dual therapy approach represents the best strategy to combat increasing antimicrobial resistance while ensuring effective treatment for patients with gonorrhea.