What is the recommended oral antibiotic regimen for treating gonorrhea?

Recommended Oral Antibiotic Treatment for Gonorrhea

For uncomplicated gonorrhea, cefixime 400 mg as a single oral dose is the recommended oral antibiotic treatment, with an efficacy of 95-98% for urogenital and rectal infections. 1

First-Line Oral Treatment Option

• Cefixime 400 mg orally in a single dose
  • FDA-approved for uncomplicated gonorrhea (cervical/urethral) 2
  • Efficacy: 95-98% cure rate for urogenital and rectal infections 1
  • Provides sustained bactericidal levels, though not as high or sustained as injectable ceftriaxone 3
  • Clinical trials demonstrated 96% cure rate (89 of 93 patients) 4

Important Considerations

Antimicrobial Resistance

• Increasing concern about antimicrobial resistance has led to changes in treatment guidelines over time
• Injectable ceftriaxone is currently preferred by CDC due to resistance concerns, but cefixime remains an effective oral option 1
• Treatment failures have been documented with cefixime monotherapy (17.8% failure rate in one study) 5

Site-Specific Efficacy

• Pharyngeal infections are more difficult to eradicate than urogenital/rectal infections 1
• Lower efficacy for pharyngeal gonorrhea with oral antibiotics compared to injectable options 1

Dual Therapy Recommendation

• If chlamydial infection has not been excluded, add:
  • Azithromycin 1g orally in a single dose, OR
  • Doxycycline 100 mg orally twice daily for 7 days 3, 1
• Combination therapy helps prevent development of resistance and treats potential co-infections 6

Alternative Oral Options (if cefixime unavailable or contraindicated)

• Fluoroquinolones (only if susceptibility is confirmed, not for empiric treatment):

  • Ciprofloxacin 500 mg orally in a single dose (99.8% efficacy for urogenital/rectal) 3
  • Ofloxacin 400 mg orally in a single dose (98.4% efficacy) 3

• Other oral cephalosporins (less preferred):

  • Cefpodoxime proxetil 200 mg
  • Cefuroxime axetil 1 g 1

• Azithromycin 2g as a single dose:

  • Effective but not recommended as first-line due to:
    • Gastrointestinal side effects (35.3% of patients) 7
    • High cost
    • Concerns about rapid antimicrobial resistance development 1

Follow-up Recommendations

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

Pitfalls to Avoid

• Using fluoroquinolones empirically without knowledge of local resistance patterns
• Failing to treat partners
• Not considering pharyngeal infection (which requires higher doses or injectable therapy)
• Inadequate treatment of potential co-infections (especially chlamydia)
• Relying solely on oral therapy in areas with high resistance patterns 1

Remember that treatment failures are usually due to reinfection rather than antimicrobial resistance, highlighting the importance of partner treatment 1.