What is the recommended treatment for gonorrhea?

Gonorrhea Treatment Recommendations

The current 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

Treatment Algorithm for Uncomplicated Gonorrhea

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 helping to prevent antimicrobial resistance 1.

Alternative Regimens (for patients with cephalosporin allergy)

• Azithromycin 2 g orally in a single dose 1

  • Requires test-of-cure in 1 week
  • Note: This regimen may cause gastrointestinal distress 2

• Spectinomycin 2 g IM in a single dose 2

  • Useful for patients who cannot tolerate cephalosporins and quinolones
  • Less effective for pharyngeal infections (only 52% effective) 2

Site-Specific Considerations

Pharyngeal Infections

• Ceftriaxone-based therapy required 1
• Pharyngeal infections are more difficult to eradicate than urogenital or rectal infections
• If using spectinomycin, pharyngeal culture should be evaluated 3-5 days after treatment 2

Urogenital and Rectal Infections

• Standard regimen of ceftriaxone 250 mg IM plus azithromycin 1 g orally 1

Special Populations

Pregnant Women

• Same regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally 1, 3, 4
• Quinolones and tetracyclines are contraindicated during pregnancy 2
• Should be retested in the third trimester unless recently treated 3, 4

HIV-Positive Patients

• Same treatment regimen as HIV-negative patients 1

Follow-Up Recommendations

• Test-of-cure is not needed for uncomplicated urogenital or rectal gonorrhea treated with the recommended regimen 1, 3
• Patients should be retested 3 months after treatment due to high reinfection rates 1, 3
• Persistent symptoms after treatment warrant culture for N. gonorrhoeae with antimicrobial susceptibility testing 2

Partner Management

• All sexual partners from the past 60 days should be evaluated and treated 2, 1
• Partners should receive the same treatment regimen as the index case 1
• Patients and partners should abstain from sexual activity until therapy is completed and symptoms have resolved 2

Evolution of Treatment Recommendations

It's important to note that treatment recommendations have evolved due to antimicrobial resistance:

• Fluoroquinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1
• Oral cephalosporins like cefixime are no longer first-line due to increasing minimum inhibitory concentrations 1
• The most recent update in 2020 increased the ceftriaxone dose to 500 mg IM 5, though many guidelines still reference the 250 mg dose

Common Pitfalls to Avoid

• Using outdated treatments like fluoroquinolones despite widespread resistance
• Neglecting partner treatment, which leads to reinfection
• Missing co-infections with Chlamydia trachomatis
• Inadequate treatment of pharyngeal infections, which require ceftriaxone-based therapy
• Forgetting to recommend retesting at 3 months post-treatment
• Not considering anatomical site when selecting treatment

By following these evidence-based recommendations, clinicians can effectively treat gonorrhea while helping to prevent the development of antimicrobial resistance.