What is the recommended treatment (tx) for gonorrhea?

Treatment of Gonorrhea

The recommended treatment for gonorrhea is a single intramuscular dose of ceftriaxone 500 mg plus doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been ruled out. 1, 2, 3

First-Line Treatment Regimen

• Ceftriaxone 500 mg IM as a single dose 1, 2

  • This is the most effective injectable antibiotic for gonorrhea treatment 4
  • Provides high and sustained bactericidal levels in the blood
  • Effective at all anatomic sites of infection (urogenital, anorectal, and pharyngeal)

• Plus (if chlamydial infection not excluded):

  • Doxycycline 100 mg orally twice daily for 7 days 1, 2

Anatomical Site Considerations

• Pharyngeal gonorrhea:

  • More difficult to eradicate than urogenital or anorectal infections 5, 1
  • Test-of-cure recommended 7-14 days after treatment 1
  • Ceftriaxone is highly effective for pharyngeal infections 5

• Urogenital and anorectal infections:

  • No test-of-cure needed if treated with recommended regimen 1
  • High cure rates with ceftriaxone 5

Evolution of Treatment Recommendations

Treatment guidelines have evolved due to increasing antimicrobial resistance:

• Previous recommendations included cefixime 400 mg orally, but this is no longer recommended as first-line therapy due to decreased effectiveness and treatment failures 5, 6
• Azithromycin (previously recommended as part of dual therapy) is no longer recommended due to rapidly increasing resistance 2, 3
• Single-dose azithromycin 2g has been shown to be effective but causes significant gastrointestinal side effects and is expensive 7

Partner Management

• All sexual partners from the previous 60 days should be evaluated and treated 5, 1
• If a patient's last sexual contact was >60 days before diagnosis, the most recent partner should be treated 5
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners no longer have symptoms 5

Alternative Regimens for Patients with Cephalosporin Allergy

• Gentamicin 240 mg IM plus azithromycin 2 g orally 1, 4
• Spectinomycin 2 g IM (if available) 5
  • Useful for patients who cannot tolerate cephalosporins
  • Less effective for pharyngeal infections

Follow-Up

• Retesting is recommended for all patients 3 months after treatment due to high reinfection rates 1
• Test-of-cure is not needed for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 1
• Test-of-cure is recommended for pharyngeal infections 7-14 days after treatment 1

Treatment Failures

For patients with persistent infection after treatment with the recommended regimen:

• Culture relevant clinical specimens
• Perform antimicrobial susceptibility testing of N. gonorrhoeae isolates 5
• Consider alternative treatment regimens based on susceptibility results

Common Pitfalls to Avoid

• Underdosing ceftriaxone (now 500 mg, not the previously recommended 250 mg)
• Using oral cephalosporins for pharyngeal infections
• Inadequate partner treatment
• Using azithromycin alone due to high resistance rates
• Failing to test for other STIs, particularly chlamydia

The shift to higher-dose ceftriaxone monotherapy (with doxycycline added for possible chlamydial co-infection) reflects the need to preserve antibiotic effectiveness and practice antimicrobial stewardship while ensuring high cure rates for all anatomical sites of infection.