What is the recommended treatment for Neisseria gonorrhea?

Recommended Treatment for Neisseria gonorrhoeae

The current recommended first-line treatment for Neisseria gonorrhoeae is ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g orally as a single dose. 1

First-Line Treatment Regimen

• Uncomplicated urogenital, rectal, and pharyngeal gonorrhea:
  • Ceftriaxone 250 mg IM as a single dose, PLUS
  • Azithromycin 1 g orally as a single dose 1, 2, 3

This dual therapy approach is critical because:

• It provides effective coverage against N. gonorrhoeae
• It treats potential co-infection with Chlamydia trachomatis
• It helps delay the emergence and spread of resistance to cephalosporins 1

Anatomical Site Considerations

Pharyngeal Infections

Pharyngeal infections are more difficult to eradicate than urogenital or rectal infections 4:

• Require ceftriaxone-based therapy
• May consider higher doses of ceftriaxone (up to 1 g) for pharyngeal infections
• Spectinomycin and gentamicin have poor efficacy in pharyngeal infections 4

Treatment Failures

If treatment failure is suspected with first-line therapy:

1. Obtain specimen for culture and antimicrobial susceptibility testing
2. Report to local public health officials within 24 hours
3. Consider alternative regimens:
   • Gentamicin 240 mg IM plus azithromycin 2 g orally, OR
   • Spectinomycin 2 g IM plus azithromycin 2 g orally 4

Special Populations

Pregnancy

• Pregnant women should not receive quinolones or tetracyclines
• Recommended treatment is the same as non-pregnant adults:
  • Ceftriaxone 250 mg IM plus azithromycin 1 g orally 4, 2, 3

HIV Infection

• Patients with HIV should receive the same treatment regimen as HIV-negative patients 4

Allergies

• For patients with cephalosporin allergy:
  • Spectinomycin 2 g IM is an alternative (though less effective for pharyngeal infections) 4

Follow-Up Recommendations

• Test-of-cure is not routinely recommended for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 2, 3
• Patients should be retested 3 months after treatment due to high rates of reinfection 2, 3
• Patients should abstain from sexual activity until therapy is completed and they and their partners no longer have symptoms 4

Partner Management

• All sexual partners from the past 60 days should be evaluated and treated 4, 1
• If the last sexual contact was >60 days before diagnosis, the most recent partner should be treated 4

Common Pitfalls to Avoid

1. Using outdated treatments: Fluoroquinolones (ciprofloxacin, ofloxacin) and oral cephalosporins (cefixime) are no longer recommended as first-line therapy due to resistance 1

2. Monotherapy: Single-drug therapy is no longer recommended due to increasing resistance patterns 1, 2, 3

3. Inadequate pharyngeal treatment: Pharyngeal infections require ceftriaxone-based therapy; other antibiotics may have insufficient efficacy 4

4. Forgetting partner treatment: Failure to treat partners leads to reinfection 4, 1

5. Missing co-infections: Always consider testing and treating for chlamydia co-infection 4, 1

The evolution of treatment guidelines reflects the ongoing challenge of antimicrobial resistance in N. gonorrhoeae, which has developed resistance to multiple antibiotics over time, including sulfonamides, tetracyclines, penicillin, and fluoroquinolones 1, 5.