What is the recommended antibiotic regimen for gonorrhea treatment?

Recommended Antibiotic Regimen for Gonorrhea Treatment

The recommended first-line treatment for uncomplicated gonorrhea is a single intramuscular dose of ceftriaxone 250 mg plus azithromycin 1 g orally in a single dose. 1

Primary Treatment Recommendation

• Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose is the recommended regimen for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1
• Azithromycin is preferred over doxycycline as the second antimicrobial due to:
  • Convenience and compliance advantages of single-dose therapy 1
  • Substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 1

Alternative Regimens

If ceftriaxone is not available:

• Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose 1
• A test-of-cure should be performed 1 week after treatment 1
• Note: Cefixime is less effective for pharyngeal gonorrhea compared to ceftriaxone 1

If patient has severe cephalosporin allergy:

• Azithromycin 2 g orally in a single dose 1
• A test-of-cure should be performed 1 week after treatment 1

Rationale for Dual Therapy

• Rising antibiotic resistance patterns necessitate combination therapy 1
• Using two antimicrobials with different mechanisms of action:
  • Improves treatment efficacy 1
  • Potentially delays emergence and spread of resistance to cephalosporins 1
• Ceftriaxone provides high and sustained bactericidal levels in the blood 1
• Dual therapy also addresses possible chlamydial co-infection 1

Special Considerations

Pregnancy

• Pregnant women should not be treated with quinolones or tetracyclines 1
• Recommended treatment is a cephalosporin (ceftriaxone preferred) 1
• If cephalosporins cannot be tolerated, spectinomycin 2 g IM as a single dose is an alternative 1

Treatment Failure

• For persistent infection after recommended treatment:
  • Culture relevant clinical specimens 1
  • Perform antimicrobial susceptibility testing 1
  • Consult infectious disease specialist 1
  • Report to CDC through local/state health department within 24 hours 1
  • Conduct test-of-cure 1 week after re-treatment 1

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 1
• If last sexual contact was >60 days before symptom onset or diagnosis, the most recent partner should be treated 1
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1

Follow-Up

• No test-of-cure is needed for uncomplicated urogenital or rectal gonorrhea treated with recommended regimens 2
• Patients should be retested 3 months after treatment due to high prevalence of reinfection 2
• Persistent symptoms warrant culture for N. gonorrhoeae with antimicrobial susceptibility testing 1

Important Clinical Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 1
• Ceftriaxone is significantly more effective than other antibiotics including cefuroxime, penicillin, and spectinomycin 3
• Azithromycin 2 g is effective but causes more gastrointestinal side effects and is expensive 1
• Azithromycin 1 g alone is insufficient for gonorrhea treatment 1

The evolution of treatment recommendations reflects the ongoing challenge of antimicrobial resistance in N. gonorrhoeae, making adherence to current guidelines critical for effective treatment and prevention of further resistance development.