What is the treatment for gonorrhea and chlamydia?

Treatment of Gonorrhea and Chlamydia

For uncomplicated gonorrhea, a single dose of ceftriaxone 500 mg IM is recommended, plus doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded. 1, 2, 3

First-Line Treatment Regimens

Gonorrhea Treatment

• Ceftriaxone 500 mg IM as a single dose 1, 2
  • For patients weighing ≥150 kg (331 lbs), consider increasing the dose
  • This is effective for urogenital, anorectal, and pharyngeal infections

Chlamydia Treatment

• Doxycycline 100 mg orally twice daily for 7 days 1, 3
  • This is now preferred over azithromycin due to better efficacy
  • Complete the full 7-day course even if symptoms resolve earlier

Special Populations and Considerations

Pregnant Patients

• Ceftriaxone 500 mg IM single dose for gonorrhea 1
• Azithromycin 1 g orally as a single dose for chlamydia (instead of doxycycline) 1
  • Doxycycline is contraindicated in pregnancy

Patients with Severe Beta-lactam Allergy

• Consult infectious disease specialist for alternative regimens
• Possible alternatives include spectinomycin 2 g IM as a single dose (if available) 1

Children and Adolescents

• For children <45 kg: Use weight-based dosing (see table below)
• For children >45 kg: Use adult dosing 1

Patient Weight (kg)	Cefixime 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

Rationale for Current Recommendations

• Antimicrobial resistance concerns:

  • N. gonorrhoeae has developed resistance to multiple antibiotics, including penicillins, tetracyclines, fluoroquinolones, and macrolides 1, 4
  • Azithromycin resistance has increased significantly (nearly 5% in 2018) 4
  • Ceftriaxone remains highly effective with <0.1% showing reduced susceptibility 4

• Dual therapy considerations:

  • Previously, dual therapy with ceftriaxone plus azithromycin was recommended 5
  • Current guidelines have moved away from routine azithromycin use due to:
    • Increasing azithromycin resistance 4
    • Antimicrobial stewardship concerns 2
    • Doxycycline's superior efficacy against chlamydia 3

Follow-Up and Partner Management

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

• Retest approximately 3 months after treatment due to high reinfection rates 1, 3

• Partner notification and treatment:

  • All sexual partners from the previous 60 days should be evaluated and treated 1
  • Expedited partner therapy can be considered where legally permitted

• Sexual activity: Patients should avoid sexual activity until:

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

Common Pitfalls and Caveats

1. Not testing for co-infections: Always test for both gonorrhea and chlamydia due to high co-infection rates
2. Inadequate treatment of pharyngeal gonorrhea: Pharyngeal infections are harder to eradicate and require ceftriaxone
3. Failing to address antimicrobial resistance: Avoid fluoroquinolones due to high resistance rates
4. Incomplete partner management: Untreated partners lead to high reinfection rates
5. Using oral cephalosporins as first-line: Cefixime is less effective than ceftriaxone, particularly for pharyngeal infections

Treatment Failures

If symptoms persist after appropriate treatment:

• Obtain culture with antimicrobial susceptibility testing
• Consider reinfection versus treatment failure
• Report suspected treatment failures to local health departments 1, 4