What is the treatment for gonorrhea (Neisseria gonorrhoeae infection)?

From the Guidelines

Gonorrhea should be treated with a combination of ceftriaxone 250 mg intramuscularly and either azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. This recommendation is based on the most recent evidence from the Centers for Disease Control and Prevention (CDC) [ 1 ], which suggests that combination therapy is the most reliably effective treatment for uncomplicated gonorrhea. The use of ceftriaxone, a third-generation cephalosporin, in combination with azithromycin or doxycycline, is recommended due to the increasing antibiotic resistance in Neisseria gonorrhoeae [ 1 ].

Key Considerations

• Cefixime is no longer recommended as a first-line treatment for gonorrhea due to declining susceptibility among urethral N. gonorrhoeae isolates [ 1 ].
• Combination therapy with ceftriaxone and azithromycin or doxycycline is recommended to ensure treatment of co-occurring pathogens, such as Chlamydia trachomatis [ 1 ].
• Patients should be advised to complete the full course of antibiotics, even if symptoms improve before finishing treatment, and to abstain from sexual activity for 7 days after completing treatment [ 1 ].
• Follow-up testing is recommended 1-2 weeks after treatment completion to confirm cure, especially in areas with high antibiotic resistance [ 1 ].

Treatment Options

• Ceftriaxone 250 mg intramuscularly plus azithromycin 1 g orally as a single dose [ 1 ].
• Ceftriaxone 250 mg intramuscularly plus doxycycline 100 mg orally twice daily for 7 days [ 1 ].

Important Notes

• The CDC's Gonococcal Isolate Surveillance Project (GISP) is a sentinel surveillance system that monitors N. gonorrhoeae antimicrobial susceptibilities [ 1 ].
• The minimum inhibitory concentration (MIC) is used to assess antimicrobial susceptibility, and isolates with cefixime or ceftriaxone MICs ≥0.5 μg/mL are considered to have "decreased susceptibility" to these drugs [ 1 ].

From the FDA Drug Label

When penicillin is contraindicated, doxycycline is an alternative drug in the treatment of the following infections: Uncomplicated gonorrhea caused by Neisseria gonorrhoeae. Urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae.

The treatment for gonorrhea (Neisseria gonorrhoeae infection) is:

• Doxycycline as an alternative to penicillin for uncomplicated gonorrhea 2
• Azithromycin for urethritis and cervicitis due to Neisseria gonorrhoeae 3

From the Research

Treatment Options for Gonorrhea

• The recommended first-line treatment for gonorrhea is dual therapy with ceftriaxone and azithromycin, which should be administered together on the same day, preferably simultaneously, and under direct observation 4, 5.
• Ceftriaxone is the foundation of currently recommended gonorrhea treatment, but there is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae 6.
• Alternative treatment options, such as gentamicin plus azithromycin and gemifloxacin plus azithromycin, have been shown to be highly effective for the treatment of urogenital gonorrhea, but may have limitations due to gastrointestinal adverse events 6.
• A single dose of cefixime (400 or 800 mg) given orally has been shown to be as effective as the currently recommended regimen of ceftriaxone (250 mg given intramuscularly) for the treatment of uncomplicated gonorrhea 7.

Specific Treatment Regimens

• Gentamicin 240 mg intramuscularly plus azithromycin 2 g orally has been shown to be effective for the treatment of urogenital gonorrhea, with a microbiological cure rate of 100% 6.
• Gemifloxacin 320 mg orally plus azithromycin 2 g orally has also been shown to be effective for the treatment of urogenital gonorrhea, with a microbiological cure rate of 99.5% 6.
• Ceftriaxone 500 mg intramuscularly plus azithromycin 1 g orally has been shown to be effective for the treatment of gonorrhea, with a clearance rate of 98% at 2 weeks after treatment 8.

Special Considerations

• Pregnant women who are infected with N gonorrhoeae should be treated with the recommended dual therapy of ceftriaxone and azithromycin 4, 5.
• A test-of-cure is not needed for individuals diagnosed with uncomplicated urogenital or rectal gonorrhea who are treated with the recommended or alternative regimens 4, 5.
• Patients with gonorrhea should be advised to be retested 3 months after treatment, as repeat infection is prevalent among patients who have been diagnosed with and treated for gonorrhea in the preceding several months 4, 5.