What is the recommended treatment for gonorrhea?

Recommended Treatment for Gonorrhea

The recommended first-line treatment for uncomplicated gonorrhea is a single intramuscular dose of ceftriaxone 250 mg plus azithromycin 1 g orally in a single dose. 1, 2

Treatment Algorithm

First-line Therapy

• Ceftriaxone 250 mg IM as a single dose
  • PLUS
• Azithromycin 1 g orally as a single dose

This dual therapy approach addresses both the gonorrhea infection and possible co-infection with Chlamydia trachomatis, while also helping to prevent the development of antimicrobial resistance 1, 2.

Alternative Regimens (when ceftriaxone is unavailable)

1. Cefixime 400 mg orally in a single dose

   • PLUS
   • Azithromycin 1 g orally in a single dose
   • Test-of-cure in 1 week is required

2. For patients with severe cephalosporin allergy:

   • Azithromycin 2 g orally in a single dose
   • Test-of-cure in 1 week is required

Anatomical Site Considerations

Different anatomical sites of infection require specific attention:

• Uncomplicated urogenital and rectal infections: Standard regimen as above
• Pharyngeal infections: Ceftriaxone-based therapy is essential as pharyngeal infections are more difficult to eradicate 1, 2

Antimicrobial Resistance Concerns

The evolution of treatment recommendations reflects the growing concern about antimicrobial resistance:

• Fluoroquinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1, 2
• Oral cephalosporins like cefixime are no longer first-line due to increasing minimum inhibitory concentrations (MICs) 1
• Ceftriaxone remains effective, but vigilance for resistance is essential 3

Special Populations

Pregnant Women

• Same regimen as non-pregnant patients: ceftriaxone 250 mg IM plus azithromycin 1 g orally 2, 4
• Quinolones and tetracyclines should be avoided during pregnancy 2
• Retesting in the third trimester is recommended 4

HIV-Positive Patients

• Same treatment regimen as HIV-negative patients 2

Follow-up Recommendations

• Test-of-cure is not needed for uncomplicated urogenital or rectal gonorrhea treated with the recommended regimen 1, 4
• Retesting is recommended 3 months after treatment due to high reinfection rates 2, 4
• For pharyngeal gonorrhea, test-of-cure should be considered due to higher treatment failure rates 2

Partner Management

• Sexual partners from the past 60 days should be identified and treated 2
• Partners should receive the same treatment regimen as the index case 2
• Patient-delivered partner therapy (PDPT) is recommended for heterosexual partners when partner treatment cannot be ensured 2

Common Pitfalls to Avoid

1. Inadequate pharyngeal treatment: Pharyngeal infections require ceftriaxone-based therapy and are more difficult to eradicate 2
2. Neglecting partner treatment: Failure to treat partners leads to reinfection 2
3. Missing co-infections: Always consider testing and treating for chlamydia co-infection 2
4. Using outdated treatments: Fluoroquinolones and oral cephalosporins as monotherapy are no longer recommended due to resistance 1

The treatment landscape for gonorrhea continues to evolve in response to antimicrobial resistance patterns. The current recommendations emphasize the importance of dual therapy with ceftriaxone and azithromycin to ensure effective treatment while preserving the efficacy of these antimicrobials for as long as possible 1, 2, 3.