Recommended Treatment for Gonorrhea
The current recommended first-line treatment for uncomplicated gonorrhea is ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose for infections of the cervix, urethra, rectum, and pharynx. 1
Primary Treatment Regimen
- Ceftriaxone 250 mg IM in a single dose is the preferred cephalosporin due to its high efficacy (99.1% cure rate for urogenital and anorectal infections) and sustained bactericidal levels in the blood 1
- Azithromycin 1 g orally in a single dose should be added to address possible chlamydial co-infection and to potentially delay emergence of cephalosporin resistance 1
- Dual therapy is strongly recommended due to rising antibiotic resistance patterns in Neisseria gonorrhoeae 1
Site-Specific Considerations
- Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone particularly important for these infections 1
- For genital infections only, treatment efficacy is high with both ceftriaxone (98%) and alternative regimens (94%), but pharyngeal (96% vs 80%) and rectal (98% vs 90%) infections show significantly better clearance with ceftriaxone 2, 3
Alternative Regimens
- If ceftriaxone is unavailable, cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally can be used, but a test-of-cure should be performed 1 week after treatment 1
- For patients with severe cephalosporin allergy, spectinomycin 2 g IM in a single dose is an option (98.2% cure rate for urogenital and anorectal infections) 4, 1
- Gentamicin 240 mg IM has been studied as an alternative but did not demonstrate non-inferiority to ceftriaxone (91% vs 98% overall clearance) 2, 3
Special Populations
- Pregnant women should not be treated with quinolones or tetracyclines; ceftriaxone is the preferred treatment 1
- Men who have sex with men (MSM) should only receive ceftriaxone-based therapy due to higher prevalence of resistant strains 1
- Patients with recent foreign travel should also receive ceftriaxone due to increased risk of resistant infections 1
Partner Management
- All sex partners from the preceding 60 days should be evaluated and treated 1, 4
- Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 4
- Expedited partner therapy has been shown to reduce retreatment rates by 45% 5
Follow-Up Recommendations
- Routine test of cure is not recommended for patients who receive the recommended treatment and whose symptoms resolve 4
- Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 4, 1
- Consider retesting all patients 3 months after treatment due to high risk of reinfection 1
Common Pitfalls and Caveats
- Azithromycin 1 g alone is insufficient for gonorrhea treatment (only 93% effective) 4
- Quinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1
- Azithromycin 2 g orally has shown efficacy against gonorrhea but causes significant gastrointestinal distress 4, 6
- Pain at the injection site is more severe with gentamicin than with ceftriaxone 2, 3