What is the recommended treatment for gonorrhea?

Treatment for Gonorrhea

The current recommended treatment for uncomplicated gonorrhea is a single 500 mg intramuscular dose of ceftriaxone. 1, 2 If chlamydial co-infection has not been excluded, concurrent treatment with doxycycline 100 mg orally twice daily for 7 days should be added.

First-Line Treatment Regimen

• Ceftriaxone 500 mg IM in a single dose 1, 2
• If chlamydial co-infection has not been excluded, add doxycycline 100 mg orally twice daily for 7 days 1, 2

This updated recommendation represents a change from previous guidelines that recommended dual therapy with ceftriaxone plus azithromycin. The change was prompted by:

• Increasing azithromycin resistance (nearly 5% of isolates in 2018) 1
• Stable susceptibility to ceftriaxone in the United States 1
• Antimicrobial stewardship concerns 2

Alternative Regimens

For patients with cephalosporin allergy:

• Limited options exist for patients with severe cephalosporin allergy 1
• Consultation with an infectious disease specialist is recommended 3

Special Populations

Pregnant Women

• Pregnant women should not be treated with quinolones or tetracyclines 3
• Ceftriaxone is the recommended treatment for pregnant women with gonorrhea 4, 5
• Pregnant women should be retested in the third trimester unless recently treated 4, 5

Men who have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains 3
• Quinolones should not be used for infections in MSM 3

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 3
• Ceftriaxone has superior efficacy for pharyngeal infections compared to alternative treatments 3

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 3
• If partners' treatment cannot be ensured, expedited partner therapy may be considered 3
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 3

Follow-Up Recommendations

• A test-of-cure is not needed for individuals with uncomplicated urogenital or rectal gonorrhea who are treated with the recommended regimen 4, 5
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 3
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 3, 4, 5

Antimicrobial Resistance Considerations

• N. gonorrhoeae has developed resistance to multiple antibiotics including sulfonamides, tetracyclines, penicillin, and more recently, quinolones 4, 5
• Continuing surveillance for ceftriaxone resistance is essential to ensuring continued efficacy of recommended regimens 2
• Quinolones (ciprofloxacin) are no longer recommended due to widespread resistance 3

Treatment Failure

• For treatment failure, culture relevant clinical specimens, perform antimicrobial susceptibility testing, and consult an infectious disease specialist 3
• Report suspected treatment failures to local or state health departments 2