Recommended Treatment for Gonorrhea
The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded. 1, 2
First-Line Treatment
Uncomplicated Gonorrhea (Urethral, Cervical, Rectal)
- Ceftriaxone 500 mg IM as a single dose
- If chlamydial co-infection is possible: Add doxycycline 100 mg orally twice daily for 7 days
- Alternative for chlamydia treatment: Azithromycin 1 g orally as a single dose (though doxycycline is preferred) 1
Pharyngeal Gonorrhea
- Ceftriaxone 500 mg IM as a single dose
- Pharyngeal infections are more difficult to eradicate than urogenital or anorectal infections 1
- Same additional treatment for possible chlamydial co-infection as above
Special Populations
Pregnant Patients
- Ceftriaxone 500 mg IM as a single dose
- Doxycycline is contraindicated in pregnancy
- Use azithromycin 1 g orally as a single dose if chlamydial infection is suspected 1, 3
Pediatric Patients
- For children >45 kg: Use adult dosing
- For children <45 kg: Weight-based dosing applies (see table below) 1
| Patient Weight (kg) | Daily Dose (mg) |
|---|---|
| 5 to 7.5 | 50 mg |
| 7.6 to 10 | 80 mg |
| 10.1 to 12.5 | 100 mg |
| 12.6 to 20.5 | 150 mg |
| 20.6 to 28 | 200 mg |
| 28.1 to 33 | 250 mg |
| 33.1 to 40 | 300 mg |
| 40.1 to 45 | 350 mg |
| >45 | 400 mg |
HIV-Positive Patients
- Same treatment regimen as HIV-negative patients 1
Alternative Regimens (for Cephalosporin Allergy or Resistance)
Options include:
- Gentamicin 240 mg IM plus azithromycin 2 g orally as a single dose (100% efficacy) 4
- Gemifloxacin 320 mg orally plus azithromycin 2 g orally as a single dose (99.5% efficacy) 4
- Ciprofloxacin 500 mg orally as a single dose (if susceptibility is confirmed) 1
- Spectinomycin 2 g IM as a single dose (note: only 52% effective for pharyngeal infections) 1
Treatment for Complicated Infections
- Disseminated gonococcal infection: Ceftriaxone 1 gram IV/IM every 24 hours 1
- Gonococcal conjunctivitis: Ceftriaxone 1 gram IM as a single dose 1
- Bacterial meningitis: Ceftriaxone 100 mg/kg (maximum 4 grams) initially, then 100 mg/kg/day 1
Follow-up and Partner Management
- Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens
- Exception: Test of cure is recommended for patients treated with spectinomycin for pharyngeal infection 1
- All sex partners from the previous 60 days should be evaluated and treated 1
- Patients should avoid sexual activity until therapy is completed and both they and their partners no longer have symptoms 1
- Retest approximately 3 months after treatment due to high reinfection rates 1
Important Considerations
- Cefixime (oral option) is indicated for uncomplicated gonorrhea but is less preferred than ceftriaxone due to lower efficacy against pharyngeal infections 5, 6
- Azithromycin 2 g as monotherapy has shown efficacy (98.9%) comparable to ceftriaxone but is associated with significant gastrointestinal side effects in about 35% of patients 7
- The increasing incidence of azithromycin resistance has led to reevaluation of dual therapy recommendations, with current guidelines favoring ceftriaxone monotherapy unless chlamydial infection is suspected 2
- Persistent symptoms after treatment warrant culture for N. gonorrhoeae with antimicrobial susceptibility testing 1
Antimicrobial Resistance Considerations
- Treatment failures are usually due to reinfection rather than antimicrobial resistance 1
- Ceftriaxone provides high and sustained bactericidal levels in the blood with a half-life of 5.8-8.7 hours 1
- Cefixime has a shorter half-life (3-4 hours) and provides less sustained bactericidal levels compared to ceftriaxone 1
- Monitoring for ceftriaxone resistance through surveillance is essential 2