What is the treatment for gonorrhea?

Treatment for Gonorrhea

The current recommended first-line 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

Treatment Regimen

First-line Treatment:

• Ceftriaxone 500 mg IM in a single dose 1
  • This higher dose (increased from previous 250 mg recommendations) is now standard due to concerns about antimicrobial resistance
  • For all anatomical sites of infection (urogenital, anorectal, pharyngeal)

Dual Therapy Considerations:

• If chlamydial infection has not been excluded:
  • Add doxycycline 100 mg orally twice daily for 7 days 1
  • OR azithromycin 1 g orally in a single dose 2
• Dual therapy rationale:
  • N. gonorrhoeae and C. trachomatis frequently coexist (up to 30% coinfection rate)
  • Helps prevent development of antimicrobial resistance 3

Special Anatomical Sites

Pharyngeal Gonorrhea:

• Requires special attention as it's more difficult to eradicate than urogenital or anorectal infections 2
• Ceftriaxone 500 mg IM is the only reliable treatment
• Test of cure recommended 7-14 days after treatment 2

Alternative Regimens (for ceftriaxone allergies)

• Gentamicin 240 mg IM plus azithromycin 2 g orally 4
• Spectinomycin 2 g IM (for pregnant women with cephalosporin allergy) 2
• Cefixime 400 mg orally plus azithromycin 1 g orally - but requires test-of-cure in 7 days 3, 5

Important: Quinolones (like ciprofloxacin) are no longer recommended due to widespread resistance 3

Special Populations

Pregnant Women:

• Ceftriaxone 500 mg IM in a single dose 6, 7
• Pregnant women should be retested in the third trimester unless recently treated 6

HIV-Positive Patients:

• Same treatment regimen as those without HIV 2

Follow-up

• Test-of-cure is not needed for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 7
• Test-of-cure is recommended for pharyngeal gonorrhea 7-14 days after treatment 2
• All patients should be retested 3 months after treatment due to high reinfection rates 7

Partner Management

• All sexual partners from the previous 60 days should be evaluated and treated 2
• Patients should abstain from sexual activity until:
  • Therapy is completed
  • Both patient and partners are asymptomatic 3

Common Pitfalls to Avoid

1. Underdosing ceftriaxone (using less than 500 mg)
2. Using oral cephalosporins for pharyngeal infections
3. Using quinolones despite widespread resistance
4. Inadequate partner treatment
5. Failure to test for other STIs (chlamydia, syphilis, HIV) 3
6. Not retesting patients after 3 months 7

The shift from previous dual therapy recommendations (ceftriaxone plus azithromycin) to the current focus on higher-dose ceftriaxone reflects the increasing concern about antimicrobial resistance, particularly rising azithromycin resistance, while maintaining effective treatment outcomes 8.