What is the recommended treatment regimen for gonorrhea?

Gonorrhea Treatment Recommendations

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg IM as a single dose, with doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded. 1, 2

First-Line Treatment

• Uncomplicated urogenital, anorectal, and pharyngeal gonorrhea:

  • Ceftriaxone 500 mg IM as a single dose 1, 2
  • If chlamydia has not been ruled out, add doxycycline 100 mg orally twice daily for 7 days 2

• Administration considerations:

  • Ceftriaxone should be administered intramuscularly within a relatively large muscle 3
  • Do not use diluents containing calcium (such as Ringer's solution) to reconstitute ceftriaxone 3

Special Populations

• Pregnant patients:

  • Ceftriaxone 500 mg IM as a single dose
  • Do not use doxycycline; use azithromycin or amoxicillin instead for chlamydia coverage 1

• Children:

  • Weight-based dosing for children <45 kg
  • Adult dosing for children >45 kg 1
  • Specific weight-based dosing chart available in guidelines 1

• HIV patients:

  • Same treatment regimen as HIV-negative patients 1

Alternative Regimens (for ceftriaxone allergy)

• Cefixime 400 mg orally as a single dose 1, 4

  • Note: Does not provide as high or sustained bactericidal levels as ceftriaxone 1
  • Effective for urogenital and anorectal infections, but less reliable for pharyngeal infections

• Spectinomycin 2 g IM as a single dose (for patients with severe beta-lactam allergy) 1

Specific Clinical Presentations

• 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 1

Follow-up and Partner Management

• Test for concurrent Chlamydia trachomatis infection and treat presumptively unless excluded 1
• All sex partners from the previous 60 days should be evaluated and treated 1
• Patients should avoid sexual activity until therapy is completed and symptoms resolve 1
• 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

Antibiotic Resistance Considerations

• N. gonorrhoeae has developed resistance to multiple antibiotics including penicillins, tetracyclines, fluoroquinolones, and macrolides 1
• The CDC updated treatment guidelines in 2020 to recommend increased ceftriaxone dosage (500 mg) and removal of routine azithromycin co-treatment due to increasing azithromycin resistance 2, 5
• Ceftriaxone resistance remains rare in the US (<0.1% with alert value MIC >0.25 mcg/mL) 5

Common Pitfalls to Avoid

1. Using outdated dual therapy with azithromycin - current guidelines recommend ceftriaxone monotherapy for gonorrhea with doxycycline only if chlamydia hasn't been excluded
2. Underdosing ceftriaxone - the recommended dose is now 500 mg (increased from previous 250 mg)
3. Failing to treat partners, which increases reinfection risk
4. Using fluoroquinolones empirically due to high resistance rates
5. Not considering pharyngeal infections, which are harder to eradicate and may require higher antibiotic doses

The current treatment approach balances individual treatment success, population protection, and antimicrobial stewardship principles while addressing the growing concern of antibiotic resistance.