What is the current treatment for gonorrhoea, specifically for local uncomplicated infections versus disseminated infections such as meningitis or septic arthritis?

Current Treatment for Gonorrhea: Local Uncomplicated vs. Disseminated Infections

For uncomplicated gonorrhea, ceftriaxone 250 mg IM as a single dose plus azithromycin 1g orally in a single dose is the recommended first-line treatment regimen. For disseminated infections such as meningitis or septic arthritis, higher doses and longer treatment durations are required.

Uncomplicated Gonococcal Infections (Urethral, Cervical, Rectal)

First-Line Treatment

• Ceftriaxone 250 mg IM in a single dose 1
• PLUS azithromycin 1g orally in a single dose (to cover potential chlamydial co-infection) 1

Alternative Regimens (if ceftriaxone unavailable or allergy)

• Spectinomycin 2g IM in a single dose (useful for patients who cannot tolerate cephalosporins and quinolones) 1
• Single-dose cephalosporin regimens such as:
  • Ceftizoxime 500 mg IM 1
  • Cefoxitin 2g IM with probenecid 1g orally 1
  • Cefotaxime 500 mg IM 1

Important Considerations

• Fluoroquinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1
• Azithromycin 2g as monotherapy is not recommended due to gastrointestinal side effects and cost, despite effectiveness 1
• Test of cure is not needed for uncomplicated infections treated with recommended regimens 1
• All sexual partners within 60 days should be evaluated and treated 1

Pharyngeal Gonococcal Infections

• Pharyngeal infections are more difficult to eradicate than urogenital or rectal infections 1
• Recommended treatment:
  • Ceftriaxone 250 mg IM in a single dose 1
  • PLUS azithromycin 1g orally in a single dose 1

Disseminated Gonococcal Infections (DGI)

Disseminated Gonococcal Infection with Arthritis or Skin Lesions

• Initial therapy:
  • Ceftriaxone 1g IV daily 2
  • Continue treatment for 24-48 hours after improvement begins 2
  • Then complete at least 7 days of total antibiotic therapy 2

Gonococcal Meningitis

• Ceftriaxone 1-2g IV every 12 hours 2
• Continue for 10-14 days 2
• Higher doses are necessary to achieve adequate CNS penetration 2

Gonococcal Endocarditis

• Ceftriaxone 1-2g IV every 12 hours 2
• Continue for at least 4 weeks 2
• Consultation with an infectious disease specialist is recommended 2

Special Considerations

Antimicrobial Resistance

• Surveillance for antimicrobial resistance is crucial for guiding therapy recommendations 1
• The Gonococcal Isolate Surveillance Project (GISP) monitors resistance patterns in the US 1
• Clinicians should perform culture and susceptibility testing if treatment failure occurs 1

Pregnancy

• Ceftriaxone is safe in pregnancy 2
• Azithromycin is preferred over doxycycline for pregnant women 2

HIV Co-infection

• Treatment recommendations are the same as for HIV-negative patients 1
• Testing for other STIs, including HIV, should be performed 3

Treatment Efficacy

• Ceftriaxone 125-250 mg IM cures >99% of uncomplicated urogenital and anorectal infections 4
• Ceftriaxone also effectively treats pharyngeal infections (>90% cure rate) 4
• For disseminated infections, higher doses and longer treatment durations achieve >95% cure rates 2

Common Pitfalls and Caveats

• Failing to treat for potential chlamydial co-infection 1, 3
• Using fluoroquinolones despite high resistance rates 1
• Inadequate dosing for disseminated infections 2
• Not screening and treating sexual partners, leading to reinfection 1
• Failing to retest patients 3-6 months after treatment due to high reinfection rates 3

Remember that treatment guidelines evolve as resistance patterns change, so staying updated with the latest CDC recommendations is essential for optimal management of gonococcal infections.