Recommended Treatment for Gonorrhea
The recommended first-line treatment for uncomplicated gonorrhea is dual therapy with ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose. 1
Primary Treatment Regimen
- Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose is the most reliably effective treatment for uncomplicated gonorrhea of the cervix, urethra, rectum, and pharynx 2, 1
- Dual therapy is recommended due to rising antibiotic resistance patterns and to address possible chlamydial co-infection 1
- Azithromycin is preferred over doxycycline due to convenience and compliance advantages of single-dose therapy 1
Alternative Regimens
- If ceftriaxone is not available: 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
- For patients with severe cephalosporin allergy: azithromycin 2 g orally in a single dose, with a test-of-cure performed 1 week after treatment 1
- Spectinomycin 2 g IM in a single dose is another option for patients with cephalosporin allergy, but has poor efficacy (only 52%) against pharyngeal gonorrhea 1
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
- Oral cephalosporins (like cefixime) are no longer recommended as first-line treatment due to declining effectiveness for urogenital gonorrhea 2
Special Populations
- For men who have sex with men (MSM): ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1
- For patients with history of recent foreign travel: ceftriaxone is the only recommended treatment 1
- For pregnant women: ceftriaxone plus azithromycin is recommended; quinolones and tetracyclines are contraindicated 1, 3
Antimicrobial Resistance Considerations
- Quinolones (ciprofloxacin) are no longer recommended due to widespread resistance 1
- Rising cefixime MICs have resulted in declining effectiveness for urogenital gonorrhea treatment 2
- Dual therapy with two antimicrobials with different mechanisms of action is recommended to improve treatment efficacy and potentially delay emergence of cephalosporin resistance 1
- Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1
Follow-Up Recommendations
- Patients with uncomplicated gonorrhea treated with recommended regimens do not need a test-of-cure 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
- Consider retesting all patients 3 months after treatment due to high risk of reinfection 1
Partner Management
- All sex partners from the preceding 60 days should be evaluated and treated 1
- If partners' treatment cannot be ensured, expedited partner therapy may be considered 1
- Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
Treatment Failure
- For treatment failure: culture relevant clinical specimens, perform antimicrobial susceptibility testing, and consult an infectious disease specialist 1
- Alternative regimens for treatment failure include azithromycin 2 g PO plus gentamicin 240 mg IM 4
Common Pitfalls and Caveats
- Azithromycin 1 g alone should never be used as monotherapy for gonorrhea due to insufficient efficacy 1
- Quinolones should not be used in MSM or patients with history of recent foreign travel due to high prevalence of resistant strains 1
- Oral cephalosporins like cefixime are less effective than ceftriaxone, especially for pharyngeal infections 2, 1
- Do not use diluents containing calcium when administering ceftriaxone due to risk of precipitation 5