What is the recommended treatment regimen for gonorrhea?

Recommended Treatment Regimen for Gonorrhea

The current recommended treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx is a single intramuscular dose of ceftriaxone 250 mg PLUS azithromycin 1 g orally in a single dose. 1

Primary Treatment Algorithm

First-line Treatment

• Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose 1
• Azithromycin is preferred over doxycycline due to convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 1, 2

Alternative Regimens (if ceftriaxone unavailable)

• Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose 1
• Test-of-cure should be performed 1 week after treatment with this alternative regimen 1

For Severe Cephalosporin Allergy

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

Rationale for Current Recommendations

Antimicrobial Resistance Considerations

• Rising cefixime MICs have resulted in declining effectiveness for urogenital gonorrhea treatment 2
• Dual therapy with two antimicrobials with different mechanisms of action is recommended to improve treatment efficacy and potentially delay emergence of cephalosporin resistance 2, 1
• Quinolones (ciprofloxacin) are no longer recommended due to widespread resistance 2

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 2, 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to alternative treatments 2, 3
• Recent research suggests that higher doses of ceftriaxone (500 mg to 1 g) may be needed for resistant strains, particularly for pharyngeal infections 4, 5

Special Populations

Men who have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 2
• Quinolones should not be used for infections in MSM 2

Patients with Recent Travel History

• Ceftriaxone is the only recommended treatment for patients with history of recent foreign travel 2
• Quinolones should be avoided due to higher prevalence of resistant strains in many regions 2

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 1, 2
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
• If partners' treatment cannot be ensured, expedited partner therapy may be considered 2

Follow-Up Recommendations

• Test of cure is not routinely recommended for patients treated with the recommended regimen 2
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 2
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 2

Important Clinical Caveats

• Azithromycin 1 g alone is insufficient for gonorrhea treatment 1
• Ceftriaxone must not be administered simultaneously with calcium-containing IV solutions 6
• For treatment failure, culture relevant clinical specimens, perform antimicrobial susceptibility testing, and consult an infectious disease specialist 1
• Recent research suggests increasing the ceftriaxone dose to 500 mg or 1 g may be necessary for highly resistant strains 4, 5

The evolution of gonorrhea treatment recommendations reflects the ongoing challenge of antimicrobial resistance. While older guidelines recommended lower doses of ceftriaxone (125 mg) 2, 7, more recent evidence supports higher doses (250-500 mg) to combat emerging resistance patterns 2, 4, 5.