What is the recommended treatment for uncomplicated Chlamydia and gonorrhea?

Treatment of Uncomplicated Chlamydia and Gonorrhea

For uncomplicated gonorrhea, a single 500 mg IM dose of ceftriaxone is recommended, and if chlamydial infection has not been excluded, concurrent treatment with doxycycline 100 mg orally twice daily for 7 days should be added. 1, 2, 3, 4

Gonorrhea Treatment

First-line Treatment

• Ceftriaxone 500 mg IM as a single dose 1, 2
  • This is an increase from the previously recommended 250 mg dose 2
  • For patients weighing >150 kg (331 lb), dose adjustment may be needed 4

Alternative Regimens (if ceftriaxone unavailable)

• Cefixime 400 mg orally as a single dose 5, 6
  • While effective (97.4% cure rate for urogenital and anorectal infections), it doesn't provide as high or sustained bactericidal levels as ceftriaxone 5
  • FDA-approved for uncomplicated gonorrhea 6

Special Considerations

• Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are no longer recommended due to widespread resistance 5, 1
• For patients with severe beta-lactam allergy, spectinomycin 2 g IM as a single dose may be used if available 1

Chlamydia Treatment

First-line Treatment

• Doxycycline 100 mg orally twice daily for 7 days 1, 4
  • Preferred over azithromycin due to higher efficacy

Alternative Regimen

• Azithromycin 1 g orally as a single dose
  • May be used when adherence to 7-day doxycycline is a concern

Dual Therapy Rationale

The recommendation for dual therapy (ceftriaxone plus doxycycline) is based on:

1. High rates of chlamydia and gonorrhea co-infection
2. Need to treat potential chlamydial infection if not excluded through testing
3. Improved antimicrobial stewardship by using targeted therapy rather than broad-spectrum antibiotics 2, 3

Treatment Considerations

Pregnant Patients

• Pregnant patients should not receive doxycycline
• Azithromycin is the recommended alternative for chlamydia in pregnancy 1
• Ceftriaxone remains the primary treatment for gonorrhea in pregnancy 1

Follow-up

• Test of cure is not routinely needed for uncomplicated gonorrhea treated with recommended regimens 1
• Retest approximately 3 months after treatment due to high reinfection rates 1, 4
• Persistent symptoms warrant culture with antimicrobial susceptibility testing 1

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 and both they and their partners no longer have symptoms 1

Antimicrobial Resistance Concerns

• N. gonorrhoeae has developed resistance to multiple antibiotics, including penicillins, tetracyclines, fluoroquinolones, and macrolides 1
• Ceftriaxone resistance remains rare in the US, but continued surveillance is essential 2, 3
• The shift from dual therapy with azithromycin to monotherapy with ceftriaxone (plus doxycycline only if chlamydia not excluded) reflects concerns about increasing azithromycin resistance and antimicrobial stewardship 2, 3

This treatment approach balances effective therapy for both infections while practicing antimicrobial stewardship and addressing the growing concern of antibiotic resistance.