Treatment of Gonococcal Infections
The recommended first-line treatment for uncomplicated gonococcal infections is 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. 1
Treatment Regimens by Infection Site
Uncomplicated Urogenital, Anorectal, and Pharyngeal Gonorrhea
First-Line 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:
- Convenience and better compliance with single-dose therapy
- Lower prevalence of gonococcal resistance to azithromycin compared to tetracyclines 1
Alternative Regimens (when ceftriaxone cannot be used):
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
- Important: A test-of-cure is required 1 week after treatment 1
If patient has severe cephalosporin allergy:
- Azithromycin 2 g orally in a single dose
- Important: A test-of-cure is required 1 week after treatment 1
Rationale for Dual Therapy
Antimicrobial Resistance Prevention: Combination therapy with two antimicrobials with different mechanisms of action may delay emergence and spread of resistance to cephalosporins 1
Treatment of Co-infections: Dual therapy addresses the high likelihood of concurrent chlamydial infection 1, 2
Enhanced Efficacy: Particularly important for pharyngeal infections, which are more difficult to eradicate than urogenital or anorectal infections 3
Special Considerations
Treatment Failure Management
If a patient experiences treatment failure with the recommended regimen:
- Culture relevant clinical specimens
- Perform antimicrobial susceptibility testing
- Consult an infectious disease specialist or CDC
- Report the case to local/state health department within 24 hours
- Conduct a test-of-cure 1 week after re-treatment
- Evaluate and treat all sexual partners from the preceding 60 days 1
Pharyngeal Infections
- Pharyngeal infections are more difficult to eradicate than urogenital or anorectal infections
- Fewer antimicrobial regimens can reliably cure >90% of gonococcal pharyngeal infections 3
- The recommended regimen is the same as for other sites, but adherence to the full treatment course is particularly important
Partner Management
- All sexual partners from the preceding 60 days should be evaluated and treated for both gonorrhea and chlamydia
- If the last sexual contact was >60 days before symptom onset or diagnosis, the most recent partner should be treated
- Patients should avoid sexual intercourse until therapy is completed and both they and their partners no longer have symptoms 1, 3
Follow-Up
- Routine test-of-cure is not recommended for patients treated with the recommended regimen for uncomplicated gonorrhea
- Patients with persistent symptoms should be evaluated by culture for N. gonorrhoeae, and any isolates should undergo antimicrobial susceptibility testing
- Due to high reinfection rates, patients should be retested in 3-6 months 2
Common Pitfalls to Avoid
Using fluoroquinolones: These are no longer recommended due to widespread antimicrobial resistance 2
Using cefixime as first-line therapy: CDC no longer recommends routine use of cefixime as a first-line regimen due to concerns about emerging resistance 1
Monotherapy: Single-drug treatment is not recommended due to the risk of treatment failure and antimicrobial resistance development 1
Inadequate partner treatment: Failure to treat partners leads to high reinfection rates 1
Insufficient dosing for pharyngeal infections: These require the full recommended dose of ceftriaxone (250 mg) to ensure cure 2
By following these evidence-based recommendations, clinicians can effectively treat gonococcal infections while helping to prevent the development of antimicrobial resistance.