What is the primary treatment for gonorrhea?

Primary Treatment for Gonorrhea

The primary treatment for gonorrhea is ceftriaxone 250 mg IM as a single dose, combined with azithromycin 1 g orally as a single dose. 1

Current Recommended Regimen

The Centers for Disease Control and Prevention (CDC) recommends the following treatment for uncomplicated gonococcal infections:

• First-line therapy:
  • Ceftriaxone 250 mg IM as a single dose
  • PLUS
  • Azithromycin 1 g orally as a single dose 2, 1

This combination therapy is highly effective against Neisseria gonorrhoeae and provides coverage for possible co-infection with Chlamydia trachomatis, which is common in patients with gonorrhea.

Rationale for Current Recommendations

The treatment recommendations have evolved over time due to increasing antimicrobial resistance:

1. Antimicrobial resistance concerns:

   • N. gonorrhoeae has developed resistance to multiple antibiotics over time, including fluoroquinolones and oral cephalosporins 1
   • In 2012, CDC no longer recommended cefixime as a first-line treatment due to declining susceptibility 2

2. Pharmacokinetic advantages:

   • Ceftriaxone provides high and sustained bactericidal levels in the blood 2
   • Ceftriaxone is highly efficacious at all anatomic sites of infection, including pharyngeal gonorrhea which is more difficult to treat 1

3. Dual therapy benefits:

   • Addresses possible co-infection with C. trachomatis
   • May delay emergence and spread of resistance to cephalosporins 2
   • Provides synergistic or additive effects against N. gonorrhoeae 3

Special Populations

Pregnant Women

• Pregnant women should not receive quinolones or tetracyclines
• Recommended treatment is ceftriaxone 250 mg IM plus azithromycin 1 g orally 1

Patients with Cephalosporin Allergy

• For patients with severe cephalosporin allergy, spectinomycin 2 g IM is an alternative
• Note that spectinomycin is less effective for pharyngeal infections 1
• Azithromycin 2 g as a single oral dose can be considered with test-of-cure in 1 week 2

Follow-Up Recommendations

• Patients should abstain from sexual activity until therapy is completed and both they and their partners no longer have symptoms 1
• All sexual partners from the past 60 days should be evaluated and treated 1
• Test of cure is not routinely recommended for patients who receive the recommended regimen and whose symptoms resolve 1

Common Pitfalls to Avoid

1. Inadequate pharyngeal treatment:

   • Pharyngeal infections require ceftriaxone-based therapy as other antibiotics have poor efficacy at this site 1
   • Cefixime and other oral antibiotics are less effective for pharyngeal gonorrhea 2

2. Neglecting partner treatment:

   • Failure to treat partners leads to reinfection 1

3. Missing co-infections:

   • Always consider testing and treating for chlamydia co-infection 1

4. Using outdated regimens:

   • Older regimens like fluoroquinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1

The evolution of gonorrhea treatment reflects the ongoing challenge of antimicrobial resistance. While the 1993 guidelines recommended multiple options including ceftriaxone 125 mg IM, cefixime 400 mg orally, ciprofloxacin 500 mg orally, or ofloxacin 400 mg orally 2, current recommendations have narrowed to ceftriaxone-based therapy due to increasing resistance patterns.