What is the recommended treatment for gonorrhea?

Recommended Treatment for Gonorrhea

The recommended first-line treatment for uncomplicated gonorrhea is ceftriaxone 500 mg IM as a single dose. 1

Treatment Regimens by Patient Type

Standard Treatment for Adults

• First-line treatment:
  • Ceftriaxone 500 mg IM as a single dose 1, 2
  • If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice daily for 7 days 2

Alternative Regimens

• For patients with severe beta-lactam allergy:
  • Spectinomycin 2 g IM as a single dose (if available) 1
• Alternative oral option:
  • Cefixime 400 mg orally as a single dose (though less preferred due to lower efficacy) 1, 3

Special Populations

Pregnant Women

• Ceftriaxone 500 mg IM as a single dose plus azithromycin 1 g orally as a single dose 1
• Doxycycline is contraindicated in pregnancy; azithromycin should be used instead 1

Children

• Weight-based dosing for children <45 kg; adult dosing for children >45 kg 1
• For specific weight-based dosing:

  Patient Weight (kg)	Daily Dose (mg)
  5 to 7.5	50 mg
  7.6 to 10	80 mg
  10.1 to 12.5	100 mg
  12.6 to 20.5	150 mg
  20.6 to 28	200 mg
  28.1 to 33	250 mg
  33.1 to 40	300 mg
  40.1 to 45	350 mg
  >45	400 mg

HIV Patients

• Same treatment regimen as HIV-negative patients 1

Treatment by Infection Site

Uncomplicated Urogenital/Anorectal/Pharyngeal Gonorrhea

• Ceftriaxone 500 mg IM as a single dose 1, 2

Disseminated Gonococcal Infection

• Ceftriaxone 1 gram IV/IM every 24 hours 1

Gonococcal Conjunctivitis

• Ceftriaxone 1 gram IM as a single dose 1

Bacterial Meningitis

• Ceftriaxone 100 mg/kg (maximum 4 grams) initially, then 100 mg/kg/day once daily or divided every 12 hours (maximum 4 grams/day) for 7-14 days 1

Antibiotic Resistance Considerations

• N. gonorrhoeae has developed resistance to multiple antibiotics, including:

  • Penicillins
  • Tetracyclines (20.6-21.6% resistance)
  • Fluoroquinolones
  • Macrolides 1

• Quinolone-resistant gonorrhea has been reported from Southeast Asia, Hawaii, and California 4

• Patients with recent travel to these areas or whose partners have traveled there should receive non-quinolone treatment 4

Partner Treatment and Follow-up

• All sex partners from the previous 60 days should be evaluated and treated 1

• Patients should avoid sexual activity until:

  • Therapy is completed
  • Both patient and partners no longer have symptoms 1

• Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens 1

• Persistent symptoms warrant culture with antimicrobial susceptibility testing 1

• Important: Retest approximately 3 months after treatment due to high reinfection rates 1, 5, 6, 7

Common Pitfalls and Caveats

1. Dual therapy evolution: While older guidelines recommended dual therapy with ceftriaxone plus azithromycin for all cases, the most recent CDC guidance (2020) has moved to ceftriaxone monotherapy for uncomplicated cases unless chlamydial infection has not been excluded 2

2. Pregnancy considerations: Never use doxycycline in pregnant women; use azithromycin instead 1

3. Antibiotic resistance monitoring: Culture and susceptibility testing should be performed in persons with apparent treatment failure 4

4. Syphilis screening: All patients with gonorrhea should be tested for syphilis, as azithromycin at gonorrhea treatment doses may mask or delay symptoms of incubating syphilis 8

5. Reinfection risk: High rates of reinfection make the 3-month follow-up testing crucial for all patients 1, 5, 6