What is the role of Ceftriaxone (Rocephin) and Azithromycin in treating sexually transmitted diseases (STDs) like gonorrhea and chlamydia?

Ceftriaxone and Azithromycin for STD Treatment

Ceftriaxone is the primary recommended treatment for gonorrhea, while azithromycin is no longer recommended as part of dual therapy due to increasing antimicrobial resistance concerns. 1

Current Treatment Recommendations for Gonorrhea

First-Line Treatment

• Uncomplicated gonorrhea (urogenital, anorectal, pharyngeal):
  • 500 mg ceftriaxone IM as a single dose 1, 2
  • For patients weighing ≥150 kg: 1 g ceftriaxone IM 3

Chlamydia Co-infection Management

• If chlamydial infection has not been excluded:
  • Add doxycycline 100 mg orally twice daily for 7 days 1, 2
  • Azithromycin is no longer the preferred agent for chlamydia co-treatment 2

Special Considerations for Gonorrhea Treatment

Pharyngeal Infections

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 4
• Test-of-cure is recommended for all cases of pharyngeal gonorrhea 7-14 days after treatment 5, 3

Pregnancy

• Ceftriaxone is safe in pregnancy 5
• Avoid quinolones and tetracyclines in pregnant women 4
• For pregnant women who cannot tolerate cephalosporins, spectinomycin 2 g IM is recommended 5

Antimicrobial Resistance Considerations

• N. gonorrhoeae has developed resistance to multiple antibiotics over time 2
• Azithromycin resistance has increased rapidly, with nearly 5% of isolates showing elevated MICs in 2018 2
• Ceftriaxone MICs have remained relatively stable in the US 2

Evolution of Treatment Guidelines

Historical Context

• Previous guidelines (2010-2015) recommended dual therapy with ceftriaxone plus azithromycin 1
• The 2020/2021 guidelines shifted to ceftriaxone monotherapy with doxycycline only for possible chlamydia co-infection 1, 2

Rationale for Changes

1. Increasing azithromycin resistance 2
2. Stable ceftriaxone susceptibility 2
3. Antimicrobial stewardship concerns 1
4. Potential impact of dual therapy on commensal organisms 1

Treatment of Chlamydia

• First-line treatment: Doxycycline 100 mg orally twice daily for 7 days 3
• Azithromycin remains FDA-approved for chlamydial infections 6 but is no longer the preferred agent

Follow-Up Recommendations

• No test-of-cure needed for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 4, 5
• Retest all patients 3 months after treatment due to high reinfection rates 5
• Evaluate and treat all sexual partners from the previous 60 days 4, 5

Partner Management

• Expedited partner therapy (EPT) has been shown to reduce retreatment rates by 45% 7
• Partners should be evaluated and treated for both gonorrhea and chlamydia if their last sexual contact with the patient was within 60 days 4

Common Pitfalls to Avoid

• Underdosing ceftriaxone (ensure proper weight-based dosing)
• Using azithromycin 1g alone for gonorrhea (high risk of resistance)
• Failing to test for and treat potential co-infections
• Neglecting partner treatment
• Using oral cephalosporins for pharyngeal infections (lower efficacy)
• Forgetting test-of-cure for pharyngeal infections

By following these evidence-based recommendations, clinicians can effectively treat STDs while helping to prevent the development of antimicrobial resistance, ultimately reducing morbidity and improving quality of life for patients.