What is the recommended post-coital (after sexual intercourse) antibiotic (abx) regimen?

Post-Coital Antibiotic Regimen Recommendations

For post-coital prophylaxis against sexually transmitted infections, ceftriaxone 125-250 mg IM as a single dose is the recommended first-line treatment, especially when gonorrhea is a concern. 1

First-Line Regimen Options

• Ceftriaxone 125-250 mg IM in a single dose is the most effective post-coital treatment for preventing gonococcal infections 1
• If chlamydial infection cannot be ruled out (which is common), add one of the following:
  • Azithromycin 1 g orally in a single dose 1
  • Doxycycline 100 mg orally twice daily for 7 days 1, 2

Alternative Regimens

• For patients who cannot tolerate ceftriaxone:

  • Cefixime 400 mg orally in a single dose (less effective for pharyngeal infections) 1
  • Spectinomycin 2 g IM in a single dose (for patients with cephalosporin allergy, but less effective for pharyngeal infections) 1

• For patients with penicillin allergy:

  • Azithromycin 2 g orally in a single dose may be considered, but has high rates of gastrointestinal side effects and is expensive 1, 3
  • Gentamicin 240 mg IM plus azithromycin 2 g orally has shown 100% efficacy in clinical trials 4

Important Clinical Considerations

• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are no longer recommended for post-coital prophylaxis due to widespread antimicrobial resistance 1, 5
• The most recent CDC guidelines (2020) have increased the recommended ceftriaxone dose to 500 mg IM for uncomplicated gonorrhea due to emerging resistance patterns 5
• Azithromycin 1 g as monotherapy is not recommended for gonorrhea due to concerns about rapid emergence of antimicrobial resistance 1

Special Populations

• For pregnant patients, avoid doxycycline and quinolones; ceftriaxone remains the first-line option 1, 2
• For patients with HIV, the same treatment regimens are recommended as for HIV-negative individuals 2

Follow-Up Recommendations

• Test-of-cure is not recommended for patients treated with the recommended regimens unless:
  • Therapeutic compliance is questionable
  • Symptoms persist
  • Reinfection is suspected 1, 2
• Consider retesting approximately 3 months after treatment due to high risk of reinfection 2

Common Pitfalls to Avoid

• Failing to treat for both gonorrhea and chlamydia simultaneously, as co-infection is common 1
• Using outdated quinolone regimens in areas with high resistance 1
• Not considering pharyngeal infections, which require higher doses of ceftriaxone (at least 125 mg) 6
• Using azithromycin 1 g as monotherapy for gonorrhea (insufficient efficacy) 1