What is the recommended first-line treatment for gonorrhea?

First-Line Treatment for Gonorrhea

The recommended first-line treatment for gonorrhea is a single intramuscular dose of ceftriaxone 500 mg. If chlamydial co-infection has not been excluded, doxycycline 100 mg orally twice daily for 7 days should be added 1, 2.

Treatment Rationale and Evolution

Current Recommendation

• Ceftriaxone 500 mg IM as a single dose is the preferred treatment due to:
  • Sustained high bactericidal levels in the blood
  • High efficacy at all anatomic sites of infection, including pharyngeal gonorrhea which is more difficult to treat
  • Low rates of resistance in the United States 3, 1
• The dosage was increased from the previously recommended 250 mg to 500 mg to ensure adequate treatment, particularly for pharyngeal infections 2

Combination Therapy Considerations

• If chlamydial infection has not been ruled out, add doxycycline 100 mg orally twice daily for 7 days 1, 2
• Previously, azithromycin was recommended as part of dual therapy, but this has changed due to:
  • Increasing azithromycin resistance (rising to nearly 5% of isolates with elevated MICs by 2018) 4
  • Antimicrobial stewardship concerns 2

Special Populations and Considerations

Alternative Regimens

• For patients with severe cephalosporin allergy, options are limited and should be guided by antimicrobial susceptibility testing 4
• Cefixime 400 mg orally as a single dose may be considered as an alternative, but it:
  • Does not provide bactericidal levels as high as ceftriaxone
  • Has limited efficacy for pharyngeal gonorrhea
  • Is no longer recommended as first-line therapy due to increasing MICs 3, 5

Specific Patient Groups

• Pregnant patients: Should not receive doxycycline; azithromycin should be used instead for chlamydial co-infection 1
• Children >45 kg: Same dosing as adults
• Children <45 kg: Weight-based dosing of ceftriaxone 1

Antimicrobial Resistance Considerations

Resistance Patterns

• N. gonorrhoeae has developed resistance to multiple antibiotics including:
  • Penicillins
  • Tetracyclines (20.6-21.6% resistance)
  • Fluoroquinolones (no longer recommended)
  • Macrolides 3, 1

Monitoring and Follow-up

• Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens
• Retest approximately 3 months after treatment due to high reinfection rates
• All sexual partners from the previous 60 days should be evaluated and treated 1
• Treatment failures should be reported and cultured with antimicrobial susceptibility testing 1, 4

Prevention of Resistance

• Continued surveillance of resistance patterns is essential
• Patients should avoid sexual activity until therapy is completed and both they and their partners no longer have symptoms 1
• Using the recommended higher dose of ceftriaxone (500 mg) helps prevent the development of resistance 2, 4

The shift from dual therapy with ceftriaxone plus azithromycin to ceftriaxone monotherapy (with doxycycline only for possible chlamydial co-infection) represents an evidence-based approach that balances effective treatment with antimicrobial stewardship principles.