What is the recommended dosage of cefixime (Cefixime) for the treatment of uncomplicated gonorrhea, a sexually transmitted infection (STI)?

Cefixime Dosage for Uncomplicated Gonorrhea

The recommended dosage of cefixime for the treatment of uncomplicated gonorrhea is 400 mg orally in a single dose. 1, 2

Evidence-Based Recommendation

Cefixime is an effective oral cephalosporin option for treating uncomplicated gonorrhea infections. The FDA-approved dosage of 400 mg as a single oral dose has demonstrated high efficacy in clinical trials, with cure rates of approximately 97.4% for uncomplicated urogenital and anorectal gonococcal infections 1.

Mechanism and Efficacy

• Cefixime has an antimicrobial spectrum similar to ceftriaxone (the injectable alternative)
• The 400 mg oral dose provides bactericidal levels, though not as high or sustained as ceftriaxone 125 mg IM 1
• Clinical trials show cure rates of 97.4% for urogenital and anorectal infections 1
• The primary advantage of cefixime is that it can be administered orally, improving treatment accessibility 1

Treatment Algorithm

1. First-line treatment:

   • Cefixime 400 mg orally in a single dose 1, 2
   • PLUS treatment for chlamydia if not ruled out:
     • Azithromycin 1 g orally in a single dose OR
     • Doxycycline 100 mg orally twice daily for 7 days

2. Alternative if cefixime is unavailable:

   • Ceftriaxone 125 mg IM in a single dose 1

3. Special considerations:

   • For pharyngeal gonorrhea: Ceftriaxone is preferred as cefixime has lower efficacy at this site 1, 3
   • For patients who cannot tolerate cephalosporins: Consider spectinomycin 2 g IM in a single dose 1

Important Caveats and Pitfalls

1. Antimicrobial resistance concerns:

   • Quinolones (ciprofloxacin, ofloxacin) should not be used for infections in men who have sex with men (MSM) or in patients with history of travel to areas with high quinolone-resistant N. gonorrhoeae (QRNG) prevalence 1
   • Recent evidence suggests increasing concern about cefixime resistance, with CDC recommending higher doses of ceftriaxone in more recent guidelines 4

2. Pharyngeal infections:

   • Cefixime is less effective for pharyngeal gonorrhea than for urogenital/rectal infections 1, 3
   • For pharyngeal gonorrhea, ceftriaxone 125 mg IM is preferred 1

3. Co-infection management:

   • Always consider treating for chlamydia co-infection if not ruled out, as co-infection is common 1
   • Medications should ideally be dispensed on-site to maximize compliance 1

4. Follow-up:

   • Patients treated with the recommended regimen generally do not need test of cure 1
   • Persistent symptoms after treatment warrant culture for N. gonorrhoeae with antimicrobial susceptibility testing 1

Special Populations

For patients with renal impairment:

• Normal dose (400 mg) for creatinine clearance ≥60 mL/min
• Reduced dose for creatinine clearance <60 mL/min 2

The 400 mg single oral dose of cefixime provides an effective balance of efficacy and convenience for treating uncomplicated gonorrhea, while addressing concerns about antimicrobial resistance and improving treatment compliance.