What is the recommended empiric treatment for gonorrhea and chlamydia?

Empiric Treatment for Gonorrhea and Chlamydia

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

First-line Treatment Regimen

• Ceftriaxone 250 mg IM in a single dose is the preferred cephalosporin for gonorrhea treatment due to its high efficacy against urogenital, anorectal, and pharyngeal infections 1
• Azithromycin 1 g orally in a single dose is added to:
  • Address possible chlamydial co-infection 1
  • Potentially delay emergence and spread of resistance to cephalosporins 1
  • Provide better compliance advantages compared to multi-day doxycycline regimens 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, 2
• A test-of-cure should be performed 1 week after treatment with this alternative regimen 1

For patients with severe cephalosporin allergy:

• Spectinomycin 2 g IM in a single dose (if available) 3
• For pharyngeal infections in patients with cephalosporin allergy, consultation with an infectious disease specialist is recommended as spectinomycin has poor efficacy (only 52%) against pharyngeal gonorrhea 3

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to alternative treatments 1
• Recent research shows that higher doses of ceftriaxone (1 g) may be needed for oropharyngeal infections caused by resistant strains 4

Special Populations

• For men who have sex with men (MSM), ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1
• For patients with history of recent foreign travel, ceftriaxone is strongly preferred due to global antimicrobial resistance patterns 1
• Pregnant women should not be treated with quinolones or tetracyclines; ceftriaxone plus azithromycin is the recommended regimen 1

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 1
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
• Expedited partner therapy may reduce retreatment rates by approximately 45% 5

Follow-Up Recommendations

• Patients with uncomplicated gonorrhea treated with recommended regimens do not need a test of cure 3
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 1
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 1

Important Clinical Considerations

• Azithromycin 1 g alone is insufficient for gonorrhea treatment (93% efficacy) 3
• Quinolones (ciprofloxacin) are no longer recommended due to widespread resistance 1
• Rising antimicrobial resistance necessitates combination therapy to improve treatment efficacy 1
• Recent research supports higher ceftriaxone doses (500 mg to 1 g) for treating resistant strains 6, 4