What is the recommended treatment for gonorrhea in a patient with allergies to penicillin (PCN) and erythromycin (ERY)?

Treatment of Gonorrhea in Patients with Penicillin and Erythromycin Allergies

For patients with allergies to penicillin and erythromycin, the recommended treatment for gonorrhea is a single 500 mg intramuscular dose of ceftriaxone, with doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1

First-line Treatment

Uncomplicated Gonococcal Infections (Urogenital, Anorectal, Pharyngeal)

• Ceftriaxone 500 mg IM as a single dose 1, 2
  • For patients weighing ≥150 kg (331 lbs), increase dose to 1 g IM 1
  • Plus treatment for possible chlamydial coinfection:
    • Doxycycline 100 mg orally twice daily for 7 days 1, 3

Alternative Regimens for Patients with Cephalosporin Allergy

If the patient also has a cephalosporin allergy (cross-reactivity with penicillin occurs in approximately 5-10% of patients), consider:

1. Gentamicin 240 mg IM as a single dose PLUS azithromycin 2 g orally as a single dose 1

   • Note: This is despite the patient's erythromycin allergy, as the high-dose azithromycin is needed for gonorrhea coverage
   • Monitor closely for adverse reactions

2. Spectinomycin 2 g IM as a single dose 4

   • Particularly useful for urogenital and anorectal infections
   • Note: Spectinomycin is less effective for pharyngeal infections (only 52% effective) 4
   • If pharyngeal infection is present, follow-up culture is required 3-5 days after treatment 4

Special Considerations

Anatomical Site of Infection

• Pharyngeal infections are more difficult to eradicate than urogenital or anorectal infections 4
  • If using spectinomycin, a test-of-cure is mandatory 3-5 days after treatment 4
  • Ceftriaxone has superior efficacy for pharyngeal infections 5

Disseminated Gonococcal Infection

• Ceftriaxone 1 g IV/IM daily for at least 7 days 4, 1
• For patients with cephalosporin allergy: Spectinomycin 2 g IM every 12 hours for at least 7 days 4

Gonococcal Conjunctivitis

• Ceftriaxone 1 g IM as a single dose 4, 1
• Consider lavage of the infected eye with saline solution once 4

Management of Sex Partners

• All sex partners from the previous 60 days should be evaluated and treated 4, 1
• Patients should avoid sexual activity until:
  • Therapy is completed
  • Both they and their partners no longer have symptoms 4

Follow-up

• Test-of-cure is not routinely recommended for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 4
• Test-of-cure is recommended for:
  • Pharyngeal infections (7-14 days after treatment) 1
  • When using alternative regimens 1
• Retest approximately 3 months after treatment due to high reinfection rates 1

Important Clinical Considerations

• Quinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1, 2
• Antimicrobial resistance monitoring is essential due to N. gonorrhoeae's ability to develop resistance to antibiotics 1, 6
• Cross-reactivity between penicillin and cephalosporins occurs in approximately 5-10% of patients, but ceftriaxone can often be safely administered to patients with non-IgE-mediated penicillin allergy
• If the patient has a history of severe immediate-type hypersensitivity to both penicillin and cephalosporins, use spectinomycin or the gentamicin/azithromycin combination

Remember that treatment failure should prompt culture with antimicrobial susceptibility testing and consultation with an infectious disease specialist.