Treatment for Gonorrhea
The current recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1, 2
Primary Treatment Regimen
- Ceftriaxone 500 mg IM once is the first-line treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 1, 2
- This represents an increase from the previously recommended 250 mg dose, reflecting updated pharmacokinetic/pharmacodynamic data and antimicrobial stewardship principles 2
- Add doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been ruled out 1, 2
The shift away from dual therapy with azithromycin occurred because azithromycin resistance rose rapidly to nearly 5% by 2018, while ceftriaxone resistance has remained stable with <0.1% of isolates showing elevated MICs in U.S. surveillance 2. This change prioritizes antimicrobial stewardship while maintaining treatment efficacy 2.
Alternative Regimens (When Ceftriaxone Unavailable)
- Cefixime 400 mg orally once PLUS azithromycin 1 g orally once 3, 4
- Critical caveat: Cefixime is less effective than ceftriaxone, particularly for pharyngeal infections, and requires a test-of-cure 1 week after treatment 3
- Cefixime MICs have been rising, resulting in declining effectiveness for urogenital gonorrhea 3
Severe Cephalosporin Allergy
- Azithromycin 2 g orally once (not 1 g, which has only 93% efficacy) 3
- Requires test-of-cure 1 week after treatment 3
- Spectinomycin 2 g IM once is an alternative, but has poor efficacy (only 52%) against pharyngeal gonorrhea 3
- Important limitation: There are no recommended alternative therapies for pharyngeal N. gonorrhoeae infection in patients with cephalosporin allergies 2
Site-Specific Considerations
Pharyngeal Gonorrhea
- More difficult to eradicate than urogenital or anorectal infections 3
- Ceftriaxone has superior efficacy compared to all alternatives 3
- The 500 mg dose is particularly important for pharyngeal infections, showing better efficacy than the previous 250 mg dose 5
Genital Infections
- Gentamicin 240 mg IM (with azithromycin 1 g) showed 94% clearance for genital infections but is not recommended as first-line therapy 6
- May be considered for isolated genital infection in patients allergic to ceftriaxone or with ceftriaxone-resistant isolates 6
Special Populations
Men Who Have Sex with Men (MSM)
- Use only ceftriaxone due to higher prevalence of resistant strains 3
- Quinolones are contraindicated in this population 3
Pregnant Women
Patients with Recent Foreign Travel
- Use only ceftriaxone due to higher risk of resistant strains 3
Follow-Up and Monitoring
- No test-of-cure needed for patients treated with recommended ceftriaxone regimen who become asymptomatic 1, 2
- Retest all patients at 3 months due to high reinfection rates (not for treatment failure, but to detect reinfection) 3
- If symptoms persist after treatment, perform culture with antimicrobial susceptibility testing 3, 2
Partner Management
- Evaluate and treat all sex partners from the preceding 60 days 3
- If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner 7
- Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 3
- Expedited partner therapy (providing prescriptions or medications directly to partners) may be considered when partner treatment cannot be ensured 3
Critical Pitfalls to Avoid
- Never use fluoroquinolones (ciprofloxacin, ofloxacin) - widespread resistance makes them obsolete despite older guidelines recommending them 3, 2, 5
- Never use azithromycin 1 g alone - only 93% efficacy and promotes resistance 3
- Do not substitute oral cefixime for ceftriaxone without understanding the reduced efficacy and need for test-of-cure 3
- Do not use the tablet/capsule formulation for otitis media in pediatric patients - suspension achieves higher peak levels 4