Are there any oral antibiotics for the treatment of gonorrhea?

Oral Antibiotics for Gonorrhea Treatment

Yes, there are oral antibiotics available for gonorrhea treatment, with cefixime 400 mg being the most effective oral option, though injectable ceftriaxone is currently preferred due to increasing antimicrobial resistance concerns. 1, 2

Available Oral Antibiotics for Gonorrhea

First-Line Oral Option:

• Cefixime 400 mg as a single oral dose 1, 2
  • FDA-approved for uncomplicated gonorrhea (cervical/urethral) 2
  • Efficacy: 95-98% cure rate for urogenital and rectal infections 1
  • Less effective for pharyngeal infections compared to ceftriaxone 3

Alternative Oral Options:

1. Fluoroquinolones (for non-resistant strains only):

   • Ciprofloxacin 500 mg as a single dose 1, 3
   • Ofloxacin 400 mg as a single dose (98.6% efficacy) 1
   • Levofloxacin 250 mg as a single dose 1

   CAUTION: Quinolones should NOT be used for:

   • Men who have sex with men (MSM)
   • Infections acquired in California or Hawaii
   • Patients with recent foreign travel history
   • Areas with high quinolone-resistant N. gonorrhoeae (QRNG) prevalence 1, 4

2. Other Oral Cephalosporins (less preferred):

   • Cefpodoxime proxetil 200 mg (96.5% efficacy for urogenital/rectal, only 78.9% for pharyngeal) 1
   • Cefuroxime axetil 1 g (95.9% efficacy for urogenital/rectal, only 56.9% for pharyngeal) 1

3. Azithromycin 2 g as a single dose:

   • Effective but not recommended due to:
     • Gastrointestinal side effects
     • High cost
     • Concerns about rapid antimicrobial resistance development 1, 5

Current Treatment Recommendations

Current First-Line Therapy:

• Injectable ceftriaxone (not oral) is now the preferred treatment due to increasing resistance to oral antibiotics 4, 6
• Most recent guidelines recommend ceftriaxone 500 mg IM as a single dose 6
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial co-infection is possible 3, 6

Clinical Considerations

Efficacy by Infection Site:

• Pharyngeal infections: More difficult to eradicate than urogenital/rectal infections
  • Oral antibiotics have lower efficacy for pharyngeal gonorrhea
  • Ceftriaxone (injectable) is more reliable for pharyngeal infections 1, 3

Antimicrobial Resistance:

• Resistance to oral antibiotics is increasing globally 7
• Cephalosporin resistance has emerged in Asia and Australia 7
• Fluoroquinolone resistance is widespread in the US, making them no longer recommended as empiric therapy 4

Follow-Up:

• Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens 1, 3
• Persistent symptoms warrant culture with antimicrobial susceptibility testing 1
• Retest approximately 3 months after treatment due to high reinfection rates 3

Special Populations

Pediatric Patients:

• Children >45 kg: Same as adult dosing
• Children <45 kg: Weight-based dosing (see dosage chart in guidelines) 3, 2

Pregnant Patients:

• Avoid doxycycline
• Ceftriaxone is preferred, but cefixime can be considered if injectable therapy is not feasible 3

Pitfalls and Caveats

• Relying solely on oral therapy may lead to treatment failures due to increasing resistance
• Using fluoroquinolones empirically without knowledge of local resistance patterns
• Failing to treat partners, which leads to reinfection
• Not considering pharyngeal infection, which requires more aggressive therapy
• Inadequate treatment of potential co-infections (especially chlamydia)

While oral antibiotics remain available for gonorrhea treatment, the increasing prevalence of resistant strains has shifted recommendations toward injectable ceftriaxone as first-line therapy for optimal outcomes and to prevent further development of antimicrobial resistance.