Recommended Oral Regimen for Uncomplicated Gonorrhea
For uncomplicated gonorrhea, the recommended oral regimen is cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose, with a test-of-cure performed 1 week after treatment. 1, 2
Primary Treatment Recommendations
- The first-line treatment for uncomplicated gonorrhea is ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose 1, 2
- When an oral regimen is required, cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose is recommended 1, 2
- Azithromycin is preferred over doxycycline due to convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline 1
- A test-of-cure should be performed 1 week after treatment with oral regimens 1, 2
Alternative Oral Regimens for Special Circumstances
- For patients with severe cephalosporin allergy, azithromycin 2 g orally in a single dose is recommended, with a test-of-cure performed 1 week after treatment 1, 2, 3
- This alternative regimen has been shown to be effective but may cause significant gastrointestinal distress 1, 4
Rationale for Dual Therapy
- Dual therapy with two antimicrobials with different mechanisms of action is recommended to improve treatment efficacy and potentially delay emergence of cephalosporin resistance 2
- The combination addresses possible chlamydial co-infection, which is common in patients with gonorrhea 2, 3
Site-Specific Considerations
- Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 1, 2
- Ceftriaxone has superior efficacy for pharyngeal infections compared to oral alternatives 2
- Cefixime has shown efficacy of 96.5% for urogenital and rectal infections, but only 78.9% for pharyngeal infections 1
Important Clinical Considerations
- Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1, 2
- Quinolones (ciprofloxacin, ofloxacin) are no longer recommended due to widespread resistance 1, 2
- Cefixime 400 mg has demonstrated efficacy comparable to ceftriaxone in clinical trials (96-98% cure rates) for urogenital and rectal infections 5, 6
- FDA has approved cefixime for treatment of uncomplicated gonorrhea 7
Partner Management
- All sex partners from the preceding 60 days should be evaluated and treated 1, 2
- Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 2
Follow-Up Recommendations
- For patients treated with oral regimens, a test-of-cure should be performed 1 week after treatment 1, 2
- The test-of-cure should ideally be performed with culture or with a NAAT if culture is not readily available 1
- Consider retesting all patients 3 months after treatment due to high risk of reinfection 2