What is the recommended treatment for uncomplicated gonorrhea?

Treatment of Uncomplicated Gonorrhea

The recommended first-line treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscular (IM) as a single dose. 1, 2

Current Treatment Recommendations

First-Line Regimen

• Ceftriaxone 500 mg IM as a single dose 1, 2
  • For patients weighing ≥150 kg (331 lbs), increase dose to 1 g IM 1
  • Administer in the gluteal muscle (preferred site) or deltoid muscle 1, 3
  • If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice daily for 7 days 1, 2

Alternative Regimens (for cephalosporin allergy or unavailability)

1. Spectinomycin 2 g IM as a single dose 4, 1

   • Note: Less effective for pharyngeal infections (only 52% effective) 1

2. Gentamicin 240 mg IM plus azithromycin 2 g orally as a single dose 1, 5

   • Clinical trial showed 100% efficacy for urogenital infections 5
   • Gastrointestinal side effects are common 5

Important Clinical Considerations

Site-Specific Treatment

• Pharyngeal infections:
  • Require higher doses of antibiotics due to difficulty in eradication 4, 1
  • Test-of-cure recommended 7-14 days after treatment, especially if using alternative regimens 1

Special Populations

• Pregnant patients:
  • Ceftriaxone is safe in pregnancy 1
  • Avoid quinolones and tetracyclines 1
  • For cephalosporin allergy: spectinomycin 2 g IM 1

Follow-up

• Patients should abstain from sexual activity until:
  • Therapy is completed
  • Both patient and partners no longer have symptoms 1
• Retest approximately 3 months after treatment due to high reinfection rates 1

Treatment Pitfalls to Avoid

1. Do not use quinolones (ciprofloxacin, ofloxacin):

   • No longer recommended due to widespread resistance 4, 1, 2

2. Azithromycin monotherapy is not recommended:

   • Increasing resistance has led to removal from recommended dual therapy 1
   • Single 2 g dose causes significant gastrointestinal distress 4, 6

3. When administering ceftriaxone:

   • Do not use diluents containing calcium (e.g., Ringer's solution) 3
   • Administer over 30 minutes if given intravenously 3

4. Partner management:

   • All sex partners from previous 60 days should be evaluated and treated 1
   • Failure to treat partners is a common cause of reinfection

Evolution of Treatment Guidelines

Treatment recommendations have evolved due to antimicrobial resistance patterns:

• Earlier guidelines (2006) included options like cefixime 400 mg orally 4, 7
• Current guidelines (2020-2025) recommend higher doses of ceftriaxone (500 mg vs. previous 250 mg) due to concerns about resistance 1, 2

The shift to ceftriaxone 500 mg IM as the sole first-line agent reflects the urgent need to preserve antibiotic effectiveness against gonorrhea in the face of increasing antimicrobial resistance 2.