What is the recommended prophylactic treatment for gonorrhea?

Prophylactic Treatment for Gonorrhea

The recommended prophylactic treatment for gonorrhea is a single intramuscular dose of ceftriaxone 500 mg plus azithromycin 1 g orally in a single dose if chlamydial infection has not been excluded. 1, 2

First-Line Regimen

The treatment of gonorrhea has evolved over time due to increasing antimicrobial resistance patterns. The most current evidence supports the following approach:

Primary Recommendation

• Ceftriaxone 500 mg IM in a single dose 1
• Plus, if chlamydial infection has not been excluded:
  • Doxycycline 100 mg orally twice daily for 7 days OR
  • Azithromycin 1 g orally in a single dose 2

The increased dosage of ceftriaxone (from previous recommendations of 250 mg to the current 500 mg) reflects the need to maintain high bactericidal levels in the blood to combat potential resistance and ensure effective treatment 1.

Alternative Regimens

For patients who cannot receive ceftriaxone (e.g., due to severe allergy), alternative options include:

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
• A test-of-cure should be performed in 1 week 2

For patients with severe cephalosporin allergy:

• Azithromycin 2 g orally in a single dose
• A test-of-cure should be performed in 1 week 2

Other alternatives with limited data:

• Gentamicin 240 mg IM plus azithromycin 2 g orally (100% efficacy in clinical trials) 3
• Gemifloxacin 320 mg orally plus azithromycin 2 g orally (99.5% efficacy in clinical trials) 3

Special Considerations

Pharyngeal Infections

Gonococcal infections of the pharynx are more difficult to eradicate than urogenital or anorectal infections. For pharyngeal gonorrhea:

• Ceftriaxone 500 mg IM in a single dose is strongly preferred 2
• Cefixime has limited efficacy for pharyngeal infections 2

Pregnancy

• Pregnant women should not be treated with quinolones or tetracyclines
• Ceftriaxone 500 mg IM in a single dose is the recommended treatment
• If cephalosporin allergy exists, spectinomycin 2 g IM can be used (though it has limited efficacy for pharyngeal infections) 2

HIV Infection

Patients with HIV should receive the same treatment regimen as those without HIV 2

Important Clinical Considerations

• Antimicrobial resistance monitoring is essential due to N. gonorrhoeae's ability to develop resistance to antibiotics
• Partner treatment is crucial - all sexual partners from the previous 60 days should be evaluated and treated 2
• Abstinence should be maintained until therapy is completed and both the patient and partners are asymptomatic 2
• Test of cure is not routinely recommended for uncomplicated gonorrhea treated with recommended regimens, except for pharyngeal infections or when alternative regimens are used 2

Common Pitfalls to Avoid

1. Underdosing ceftriaxone - The recommended dose has increased from 125 mg to 250 mg to now 500 mg due to concerns about resistance
2. Monotherapy - Using only ceftriaxone without addressing possible chlamydial coinfection
3. Inadequate partner treatment - Failing to ensure all recent sexual partners receive treatment
4. Using oral cephalosporins for pharyngeal infections - These have lower efficacy rates compared to injectable ceftriaxone
5. Using azithromycin 1 g alone - This is insufficiently effective, curing only 93% of patients 2

By following these evidence-based recommendations, clinicians can effectively treat gonorrhea while helping to prevent the development of further antimicrobial resistance.