What are the recommended treatments for gonorrhea and HSV (Herpes Simplex Virus) 1 infections?

Treatment of Gonorrhea and HSV-1 Infections

Gonorrhea Treatment

For uncomplicated gonorrhea, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose. 1

Primary Treatment Recommendations:

• Ceftriaxone is the foundation of currently recommended gonorrhea treatment due to increasing antimicrobial resistance 2
• The dual therapy approach helps prevent emergence of resistance and treats possible chlamydial co-infection 1
• Ceftriaxone provides sustained, high bactericidal levels in the blood and is effective for all anatomic sites of infection, including pharyngeal infections which are more difficult to eradicate 3, 1

Alternative Regimens (if ceftriaxone is unavailable):

• 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, options include:
  • Spectinomycin 2 g IM in a single dose (though it has poor efficacy against pharyngeal gonorrhea) 3
  • Gentamicin 240 mg IM plus azithromycin 2 g orally (though gastrointestinal side effects may limit routine use) 4

Special Considerations:

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 3, 1
• Quinolones (ciprofloxacin) are no longer universally recommended due to widespread resistance 3, 1
• Pregnant women should not be treated with quinolones or tetracyclines; cephalosporins are preferred 3
• All sex partners from the preceding 60 days should be evaluated and treated 1
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1

HSV-1 Treatment

For HSV-1 infections, famciclovir is FDA-approved for treatment of recurrent episodes of herpes labialis (cold sores) and genital herpes in immunocompetent adults. 5

Dosing Recommendations:

• For herpes labialis (cold sores): 1500 mg as a single dose 5
• For recurrent genital herpes episodes: 1000 mg twice daily for 1 day 5
• For suppressive therapy of recurrent genital herpes: 250 mg twice daily 5
• For immunocompromised patients (HIV-infected): 500 mg twice daily for 7 days for recurrent episodes of orolabial or genital herpes 5

Important Clinical Considerations:

• Famciclovir is a prodrug of penciclovir, a deoxynucleoside analog DNA polymerase inhibitor 5
• Dosage adjustment is necessary for patients with renal impairment 5
• The most common adverse events reported in clinical trials were headache and nausea 5
• Famciclovir has not been established for treatment of first episodes of genital herpes 5
• For black and African American patients with recurrent genital herpes, efficacy and safety have not been established 5

Treatment Monitoring and Follow-up

Gonorrhea:

• 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

HSV-1:

• No specific follow-up is typically required for immunocompetent patients with good response to therapy
• For patients with frequent recurrences, consider suppressive therapy with famciclovir 250 mg twice daily 5

Treatment Failures

• For gonorrhea treatment failures, culture relevant clinical specimens, perform antimicrobial susceptibility testing, and consult an infectious disease specialist 1
• For persistent HSV-1 infections despite appropriate therapy, consider resistance testing and alternative antiviral agents