What is the alternative treatment for gonorrhea (GC) and chlamydia when Rocephin (ceftriaxone) cannot be used?

Alternative Treatment Options for Gonorrhea and Chlamydia When Ceftriaxone Cannot Be Used

For patients with ceftriaxone allergy or contraindications, azithromycin 2g orally in a single dose is the recommended alternative treatment for gonorrhea, with concurrent treatment for chlamydia using appropriate alternatives. 1

Alternative Treatment Regimens for Gonorrhea

First-line Alternatives

• Spectinomycin 2g IM in a single dose is an effective alternative for uncomplicated urogenital and anorectal gonococcal infections, with cure rates of 98.2% 2
• Gentamicin 240mg IM plus azithromycin 2g orally has shown 100% efficacy for urogenital gonorrhea in clinical trials 3
• Gemifloxacin 320mg orally plus azithromycin 2g orally has demonstrated 99.5% efficacy for urogenital gonorrhea 3

Other Cephalosporin Options

• Single-dose cephalosporin regimens that can be used include:
  • Ceftizoxime 500mg IM
  • Cefoxitin 2g IM with probenecid 1g orally
  • Cefotaxime 500mg IM 2

Quinolone Options (If Susceptibility Confirmed)

• Quinolones should only be used if susceptibility has been confirmed due to widespread resistance 4
• Options include:
  • Ciprofloxacin 500mg orally in a single dose
  • Ofloxacin 400mg orally in a single dose
  • Levofloxacin 250mg orally in a single dose 2

Treatment for Chlamydia

First-line Options

• Azithromycin 1g orally in a single dose 2
• Doxycycline 100mg orally twice daily for 7 days 2, 5

Alternative Options for Chlamydia

• Erythromycin base or ethylsuccinate 50mg/kg/day orally divided into four doses daily for 14 days (particularly for children or when other options are contraindicated) 2
• For pregnant women: erythromycin or amoxicillin is recommended as doxycycline, quinolones, and tetracyclines are contraindicated 2

Special Considerations

Test of Cure Requirements

• A test of cure should be performed 1 week after treatment with alternative regimens 1, 6
• Culture is the preferred method for test of cure as it allows for antimicrobial susceptibility testing 6
• If culture is not available, NAAT can be used, but may detect residual DNA/RNA from dead organisms 6

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 4
• Spectinomycin has poor efficacy (only 52%) against pharyngeal gonorrhea 4
• Gentamicin/azithromycin has shown efficacy for pharyngeal (10/10) and rectal (1/1) infections 3
• Gemifloxacin/azithromycin has shown efficacy for pharyngeal (15/15) and rectal (5/5) infections 3

Common Pitfalls to Avoid

• Failing to treat for both gonorrhea and chlamydia concurrently due to high rates of co-infection 1, 4
• Using azithromycin 1g alone for gonorrhea treatment, which is insufficient with only 93% efficacy 4
• Not considering antimicrobial resistance patterns when selecting alternative treatments 7
• Not performing a test of cure when using alternative regimens 6

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated 2, 6
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 2, 6

Treatment Failure Management

• For suspected treatment failures, obtain specimen for culture and antimicrobial susceptibility testing 6
• Report the case to local public health officials within 24 hours 6
• Consult an infectious disease specialist for guidance on alternative treatment options 1, 6