What is the recommended treatment regimen for gonorrhea?

Recommended Treatment for Gonorrhea

The Centers for Disease Control and Prevention recommends ceftriaxone 500 mg IM in a single dose as the first-line treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. 1

Primary Treatment Recommendations

• For uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx, ceftriaxone 500 mg IM in a single dose is the current standard of care 1
• If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 1
• Previously, the CDC recommended ceftriaxone 250 mg IM plus azithromycin 1 g orally in a single dose, but this was updated due to increasing azithromycin resistance and antimicrobial stewardship concerns 2, 1

Alternative Regimens

• If ceftriaxone is not available, cefixime 400 mg orally in a single dose can be used, but a test-of-cure should be performed 1 week after treatment due to lower efficacy, particularly for pharyngeal infections 2, 3
• For patients with severe cephalosporin allergy, options include:
  • Gentamicin 240 mg IM plus azithromycin 2 g orally in a single dose 2, 4
  • Azithromycin 2 g orally in a single dose (with test-of-cure 1 week after treatment) 2

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 2
• Ceftriaxone has superior efficacy for pharyngeal infections compared to alternative treatments 2, 5
• Research shows gentamicin is less effective than ceftriaxone, particularly for pharyngeal infections (80% vs 96% clearance) 5

Special Populations

• For pregnant women, cephalosporins (preferably ceftriaxone) are recommended as quinolones and tetracyclines are contraindicated 2
• Men who have Sex with Men (MSM) should only receive ceftriaxone due to higher prevalence of resistant strains 2
• Patients with history of recent foreign travel should only receive ceftriaxone due to higher risk of resistant strains 2

Administration and Dosing

• Ceftriaxone should be administered as an intramuscular injection well within the body of a relatively large muscle 6
• For adults, the recommended dose is 500 mg IM in a single dose 1
• For pediatric patients with uncomplicated gonorrhea, the recommended total daily dose is 50-75 mg/kg (not to exceed 2 grams) 6

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 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 may be considered 2

Treatment Failure Management

• For treatment failure, culture relevant clinical specimens and perform antimicrobial susceptibility testing 2
• Consult an infectious disease specialist for guidance on alternative regimens 2
• Consider alternative regimens such as azithromycin 2 g plus gentamicin 240 mg IM, or ertapenem 1 g IM for 3 days 7

Follow-Up Recommendations

• Patients with uncomplicated gonorrhea treated with recommended regimens do not need a test of cure 2
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 2
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 2

Important Clinical Considerations

• Rising antibiotic resistance necessitates adherence to current treatment guidelines 2, 1
• Quinolones (ciprofloxacin) are no longer recommended due to widespread resistance 2
• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 2