What is the recommended treatment for uncomplicated gonorrhea?

Treatment of Uncomplicated Gonorrhea

The recommended first-line treatment for uncomplicated gonorrhea is dual therapy with ceftriaxone 250 mg intramuscularly in a single dose PLUS azithromycin 1 g orally in a single dose. 1

Primary Treatment Recommendation

• Dual therapy with ceftriaxone and azithromycin is the only recommended first-line regimen for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 2
• The medications should be administered together on the same day, preferably simultaneously, and under direct observation 2, 3
• Azithromycin is preferred over doxycycline due to:
  • Convenience and compliance advantages of single-dose therapy 4, 1
  • Substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 4, 1

Rationale for Dual Therapy

• Rising antibiotic resistance patterns necessitate combination therapy to improve treatment efficacy 4, 1
• Dual therapy potentially delays emergence and spread of resistance to cephalosporins 4, 1
• This approach also addresses possible chlamydial co-infection 1, 2
• Maintaining effectiveness of ceftriaxone for as long as possible is critical as it is the last highly effective antimicrobial for gonorrhea treatment 4

Alternative Regimens

• If ceftriaxone is not available:

  • Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose 4, 1
  • A test-of-cure should be performed 1 week after treatment 4, 1
  • Note that cefixime has limited efficacy for pharyngeal gonorrhea compared to ceftriaxone 4

• For patients with severe cephalosporin allergy:

  • Azithromycin 2 g orally in a single dose 4, 1
  • A test-of-cure should be performed 1 week after treatment 4, 1
  • Be aware that azithromycin 2 g is associated with a relatively high frequency of gastrointestinal side effects 5

Special Considerations

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to alternative treatments 1

Special Populations

• Pregnant women should be treated with the recommended dual therapy (ceftriaxone plus azithromycin) 2, 3
• Ceftriaxone is the only recommended treatment for men who have sex with men (MSM) due to higher prevalence of resistant strains 1
• Patients with history of recent foreign travel should receive ceftriaxone-based therapy 1

Partner Management and Follow-Up

• All sex partners from the preceding 60 days should be evaluated and treated 1, 6
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
• A test-of-cure is not needed for individuals with uncomplicated urogenital or rectal gonorrhea treated with the recommended regimens 2, 3
• Patients should be retested 3 months after treatment due to high risk of reinfection 1, 2
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 2, 3

Common Pitfalls and Caveats

• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1
• Quinolones (e.g., ciprofloxacin) are no longer recommended due to widespread resistance 1
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 1
• When administering ceftriaxone intramuscularly, inject well within the body of a relatively large muscle; aspiration helps avoid unintentional injection into a blood vessel 7