What is the recommended treatment for gonorrhea?

Gonorrhea Treatment Guidelines

The recommended first-line treatment for uncomplicated gonorrhea is ceftriaxone 500 mg IM as a single dose, plus azithromycin 1 g orally as a single dose if chlamydial coinfection has not been excluded. 1, 2

First-Line Treatment Regimen

Uncomplicated Gonorrhea (urogenital, anorectal, pharyngeal)

• Ceftriaxone 500 mg IM as a single dose 1, 2
• If chlamydial infection has not been excluded, add:
  • Azithromycin 1 g orally as a single dose OR
  • Doxycycline 100 mg orally twice daily for 7 days 1, 2

Note: Ceftriaxone is the preferred treatment due to its high efficacy and low resistance rates. The dose has been increased from previous recommendations (125 mg to 500 mg) due to emerging antimicrobial resistance concerns 1, 3.

Alternative Regimens (for patients with severe beta-lactam allergy)

• Spectinomycin 2 g IM as a single dose (if available) 1
• Gentamicin or ofloxacin may be considered as alternative therapeutics for drug-resistant gonorrhea 4

Special Considerations

Pregnancy

• Pregnant women should receive the same regimen as non-pregnant adults (ceftriaxone 500 mg IM plus azithromycin 1 g orally) 1, 5
• Important: Doxycycline is contraindicated in pregnancy 1

Children

• Weight-based dosing for children <45 kg; adult dosing for children >45 kg 1
• For specific weight-based dosing, refer to the pediatric dosage chart in the guidelines 1

HIV Patients

• Patients with HIV should receive the same treatment regimen as HIV-negative patients 1

Antimicrobial Resistance Considerations

• N. gonorrhoeae has developed resistance to multiple antibiotics, including penicillins, tetracyclines, fluoroquinolones, and macrolides 1, 3
• Ceftriaxone resistance remains rare in the United States (<0.1% with alert value MIC >0.25 mcg/mL) 3
• Azithromycin resistance has increased rapidly, with nearly 5% of isolates showing elevated MICs in 2018 3

Partner Management

• All sex partners from the previous 60 days should be evaluated and treated 1
• Patients should avoid sexual activity until:
  • Therapy is completed
  • Both they and their partners no longer have symptoms 1

Follow-Up

• Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens 1
• Persistent symptoms warrant culture with antimicrobial susceptibility testing 1
• Retest approximately 3 months after treatment due to high reinfection rates 1, 5

Pitfalls and Caveats

1. Avoid monotherapy with azithromycin: Despite azithromycin's efficacy against gonorrhea, it should not be used as monotherapy due to increasing resistance patterns 1, 3

2. Pharyngeal gonorrhea: Infections of the pharynx are more difficult to eradicate and require the recommended ceftriaxone-based regimen 6

3. Gastrointestinal side effects: Higher doses of azithromycin (2g) have been associated with significant gastrointestinal side effects in approximately 35% of patients 7

4. Concurrent STI testing: All patients with gonorrhea should be tested for other STIs, including HIV and syphilis 6, 1

5. Cefixime is not preferred: While cefixime 400 mg orally is FDA-approved for uncomplicated gonorrhea 8, it is not the preferred treatment due to lower efficacy compared to ceftriaxone, especially for pharyngeal infections 1