What is the recommended management for a patient with a lab test positive for chlamydia and a positive Nucleic Acid Amplification Test (NAAT) for gonorrhea?

Management of Chlamydia and Gonorrhea Co-infection

For patients with positive lab tests for both chlamydia and gonorrhea, dual antimicrobial therapy targeting both infections is required, consisting of ceftriaxone 250mg IM single dose for gonorrhea plus either azithromycin 1g orally single dose or doxycycline 100mg orally twice daily for 7 days for chlamydia. 1

Treatment Regimen

First-line Treatment:

• Ceftriaxone 250mg IM in a single dose for gonorrhea 1
• PLUS one of the following for chlamydia:
  • Azithromycin 1g orally in a single dose 1, 2
  • OR Doxycycline 100mg orally twice daily for 7 days 1, 3

Alternative Regimens (if first-line cannot be used):

• For chlamydia alternatives:
  • Erythromycin base 500mg orally four times daily for 7 days 1
  • OR Erythromycin ethylsuccinate 800mg orally four times daily for 7 days 1
  • OR Levofloxacin 500mg orally once daily for 7 days 1
  • OR Ofloxacin 300mg orally twice daily for 7 days 1

Important Considerations

Antibiotic Resistance:

• Quinolones (ciprofloxacin) should NOT be used for gonorrhea treatment due to widespread quinolone-resistant N. gonorrhoeae (QRNG) 1
• QRNG is particularly common among men who have sex with men (MSM), in certain geographic regions (e.g., California, Hawaii), and in infections acquired during international travel 1

Follow-up Testing:

• Because nonculture tests (like NAAT) cannot provide antimicrobial susceptibility results, culture and susceptibility testing should be performed in cases of persistent infection after treatment 1
• Test-of-cure is not routinely recommended for uncomplicated infections if recommended treatment is used and symptoms resolve 1

Partner Management:

• All sex partners from the past 60 days should be referred for evaluation and treatment 1
• Patients and partners should abstain from sexual intercourse until therapy is completed (7 days after single-dose therapy or until completion of 7-day regimen) and symptoms have resolved 1

Additional Testing

• All patients with gonorrhea or chlamydia should also be tested for other STIs, including:
  • Syphilis 1
  • HIV 1

Special Populations

Pregnant Women:

• Pregnant women should receive the same treatment regimens, with the exception that doxycycline is contraindicated during pregnancy 1
• Azithromycin is the preferred treatment for chlamydia during pregnancy 1, 2

MSM and High-Risk Populations:

• Consider screening for pharyngeal and rectal infections in MSM and other high-risk groups 4
• Culture is generally the preferred method for diagnosing gonorrhea in nongenital sites (rectum, pharynx), though some labs have validated NAATs for these sites 1, 4

Common Pitfalls and Caveats

• Presumptive treatment without waiting for test results is common practice (45.2% of positive cases receive presumptive treatment) and can reduce complications and prevent loss to follow-up 5, 6
• However, approximately 10.1% of persons with negative tests may receive unnecessary presumptive treatment 5
• Women are 4 times more likely than men to have discordant results (NAAT positive but culture negative), which can lead to diagnostic and treatment uncertainties 7
• Asymptomatic individuals are 2.3 times more likely to have discordant results than those with symptoms 7
• Up to 26% of patients with positive tests who are not treated presumptively may have no treatment recorded within 30 days, highlighting the importance of follow-up systems 5

By following these evidence-based recommendations, you can effectively manage patients with co-infection of chlamydia and gonorrhea, reduce complications, and prevent transmission to partners.