What is the treatment for gonorrhea in patients allergic to ceftriaxone (Rocephin)?

Treatment for Gonorrhea in Patients Allergic to Ceftriaxone (Rocephin)

For patients with severe cephalosporin allergy, azithromycin 2 g orally in a single dose is the recommended alternative treatment for gonorrhea, with a test-of-cure performed 1 week after treatment. 1, 2

Primary Alternative Treatment Options

• Azithromycin 2 g orally in a single dose is the recommended treatment for patients with severe cephalosporin allergy, though this is not recommended for widespread use due to concerns about emerging antimicrobial resistance to macrolides 1, 2
• A test-of-cure should be conducted 1 week after treatment with this alternative regimen to ensure eradication of infection 1, 2
• Because data are limited regarding alternative regimens for treating gonorrhea among persons with severe cephalosporin allergy, providers treating such patients should consult infectious disease specialists 1

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or rectal infections, with lower clearance rates when using alternative regimens 2, 3
• For genital infections, alternative regimens may have better efficacy than for pharyngeal infections 3
• The test-of-cure for alternative regimens should ideally be performed with culture or with a NAAT if culture is not readily available 1

Testing After Treatment

• If using azithromycin as an alternative treatment, a test-of-cure should be performed 1 week after treatment 1, 4
• Culture is the preferred method for test-of-cure as it allows for antimicrobial susceptibility testing 4
• If culture is not available, NAAT can be used, but it may detect residual DNA/RNA from dead organisms, potentially leading to false positives if performed too early 4

Treatment Failure Management

• For suspected treatment failures, obtain specimen for culture and antimicrobial susceptibility testing 4, 2
• Report the case to local public health officials within 24 hours 1, 4
• Consult an infectious disease specialist for guidance on alternative treatment options 1, 4, 2

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 4, 2
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 2
• If partners' treatment cannot be ensured, expedited partner therapy should be considered 1, 2

Important Clinical Considerations

• Due to high rates of co-infection, patients treated for gonococcal infection should also be treated routinely with a regimen effective against uncomplicated genital Chlamydia trachomatis infection 1
• For patients with gonorrhea who are also infected with chlamydia, doxycycline 100 mg twice daily for 7 days should be added to the treatment regimen 5
• Pregnant women should not be treated with doxycycline, quinolones, or tetracyclines; either erythromycin or amoxicillin is recommended for treatment of chlamydia during pregnancy 1

Research on Alternative Treatments

• A single oral dose of azithromycin 2 g has been shown to be effective against uncomplicated gonococcal infections with cure rates of 98.9% in clinical trials 6
• However, gastrointestinal side effects occurred in 35.3% of patients given azithromycin 2 g, with moderate symptoms in 10.1% and severe symptoms in 2.9% 6
• Gentamicin has been studied as an alternative but was found to be less effective than ceftriaxone, particularly for pharyngeal and rectal infections, though it may be potentially useful for isolated genital infections 3

Remember that antimicrobial resistance in N. gonorrhoeae is a major public health concern, and treatment options are limited. Consultation with an infectious disease specialist is strongly recommended when treating patients with cephalosporin allergies.