Empiric Treatment for Gonorrhea in Men
The recommended empiric treatment for gonorrhea in men is ceftriaxone 500 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 7 days. 1
First-Line Treatment Regimen
The most current evidence supports a combination therapy approach for treating gonorrhea due to increasing antimicrobial resistance:
This combination therapy addresses both gonorrhea and 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 antimicrobial resistance patterns:
- Earlier guidelines (2012) recommended ceftriaxone 250 mg IM plus either azithromycin or doxycycline 3
- By 2020, the dose of ceftriaxone was increased to 500 mg IM due to concerns about emerging resistance 2
- Cefixime is no longer recommended as first-line therapy due to declining susceptibility among N. gonorrhoeae isolates 3
Alternative Treatment Options
For patients who cannot receive ceftriaxone, alternative regimens include:
- Gentamicin 240 mg IM plus azithromycin 2 g orally as a single dose 1
- Spectinomycin 2 g IM as a single dose (note: less effective for pharyngeal infections) 1
Important Clinical Considerations
Test of cure: If cefixime is used as an alternative agent, patients should return in 1 week for a test-of-cure at the site of infection 3
Partner treatment: All sex partners from the previous 60 days should be evaluated and treated to prevent reinfection 1
Post-treatment precautions: Patients should abstain from sexual activity until:
- Therapy is completed
- Both they and their partners no longer have symptoms 1
Follow-up testing: Patients should be retested approximately 3 months after treatment due to high reinfection rates 1
Pharyngeal infections: These require special attention as they are more difficult to eradicate and may require test-of-cure 7-14 days after treatment 1
Antimicrobial Resistance Concerns
The emergence of ceftriaxone-resistant strains is a major concern, particularly associated with travel to Asia 4. The first global treatment failure with dual therapy was reported in 2016, and the first isolates with combined ceftriaxone resistance and high-level azithromycin resistance were reported in 2018 4.
Efficacy of Recommended Treatments
Ceftriaxone has demonstrated excellent efficacy in clinical trials:
- 99% eradication rate for urethral infections 5
- 98% eradication rate for rectal infections 5
- 100% eradication rate for pharyngeal infections 5
Network meta-analysis has identified ceftriaxone as the most effective injectable drug (p-score of 0.924) and azithromycin as the most effective oral drug (p-score of 0.8633) for treating gonorrhea 6.
By following these evidence-based recommendations, clinicians can provide optimal care for men with gonorrhea while helping to combat the growing problem of antimicrobial resistance.