What is the recommended first-line treatment for gonococcal infection according to the World Health Organization (WHO) 2016 guidelines?

WHO 2016 Guidelines for Gonococcal Infection

I cannot provide specific WHO 2016 guideline recommendations because the evidence provided does not include the actual WHO 2016 guidelines. The available evidence consists primarily of Taiwan guidelines from 2010 and CDC-based recommendations from more recent years (2020-2025).

Current Evidence-Based Recommendations (Non-WHO)

Based on the most recent and highest quality guidelines available, the recommended first-line treatment for uncomplicated gonococcal infections is ceftriaxone 500 mg intramuscularly as a single dose, with concurrent treatment for chlamydia using doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the current CDC-recommended first-line therapy for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 1
• This represents an update from the previous 250 mg dose, reflecting evolving resistance patterns 1
• Dual therapy with azithromycin is no longer routinely recommended due to antimicrobial stewardship concerns and increasing azithromycin resistance 1
• If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice daily for 7 days 1

Alternative Regimens When Ceftriaxone Unavailable

• Cefixime 400 mg orally once PLUS azithromycin 1 g orally once can be used when ceftriaxone is unavailable 2, 3
• Critical caveat: Cefixime is significantly less effective than ceftriaxone, particularly for pharyngeal infections 4, 2
• Mandatory test-of-cure at 1 week is required when using cefixime 4, 2

Severe Cephalosporin Allergy

• Azithromycin 2 g orally as a single dose for patients with severe cephalosporin allergy 2, 3
• Mandatory test-of-cure at 1 week after treatment 2, 3
• Gentamicin 240 mg IM is NOT recommended as first-line therapy due to inferior efficacy, particularly for pharyngeal (80% cure) and rectal (90% cure) infections compared to ceftriaxone (96% and 98% respectively) 5

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 3
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives 3
• Never use cefixime as first-line therapy due to declining effectiveness and rising minimum inhibitory concentrations (MICs) 4, 3

Special Populations

Men Who Have Sex With Men (MSM)

• Use ONLY ceftriaxone due to higher prevalence of resistant strains 2, 3
• Quinolones are absolutely contraindicated in this population 2, 3

Pregnant Women

• Ceftriaxone is the preferred treatment 2, 6
• Quinolones and tetracyclines are contraindicated 2, 3
• Dual therapy with ceftriaxone and azithromycin should be used 6
• Retest in third trimester if antenatal gonococcal infection was present 6

HIV-Infected Patients

• Use the same treatment regimen as HIV-negative patients 4
• Treatment is particularly vital as cervicitis increases cervical HIV shedding and may increase HIV transmission 4

Partner Management

• All sex partners from the preceding 60 days must be evaluated and treated 2, 3
• If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner 2
• Patients and partners must abstain from sexual intercourse until therapy is completed (7 days after single-dose regimen) and both are asymptomatic 4, 3
• Expedited partner therapy may be considered if partners' treatment cannot be ensured 3

Concurrent Testing Requirements

• Screen for syphilis with serology at the time of gonorrhea diagnosis 2
• Test for both N. gonorrhoeae and C. trachomatis using nucleic acid amplification tests (NAATs), which are the most sensitive and specific tests available 4
• Assess for signs of pelvic inflammatory disease (PID) 4
• Evaluate for bacterial vaginosis and trichomoniasis, treating if present 4

Treatment Failure Management

• For persistent infection after recommended treatment, culture relevant clinical specimens and perform antimicrobial susceptibility testing 4, 3
• Consult an infectious disease specialist or CDC 4
• Report the case to CDC through local or state health department within 24 hours 4
• Conduct test-of-cure 1 week after re-treatment 4

Follow-Up Recommendations

• Patients with uncomplicated gonorrhea treated with recommended regimens do NOT need routine test-of-cure 3
• Retest all patients 3 months after treatment due to high risk of reinfection (most infections result from reinfection, not treatment failure) 3, 7, 6
• Patients with persistent symptoms should be evaluated by culture with antimicrobial susceptibility testing 3

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, levofloxacin) for gonorrhea treatment due to widespread resistance 3, 7
• Never use azithromycin 1 g alone for gonorrhea treatment—it has only 93% efficacy 3
• Do not rely on cefixime as first-line therapy due to declining effectiveness 4
• Ceftriaxone has superior efficacy for pharyngeal infections and is strongly preferred over cefixime 3

Rationale for Evolving Recommendations

• Rising antibiotic resistance patterns necessitate ongoing reevaluation of treatment regimens 3, 1
• Recent evidence suggests ceftriaxone 1 g may be needed to eradicate currently spreading ceftriaxone-resistant strains, particularly for oropharyngeal infections 8
• Antimicrobial stewardship concerns and increasing azithromycin resistance led to removal of routine dual therapy with azithromycin 1
• Co-infection with chlamydia remains common (40-50% of gonorrhea cases), making presumptive chlamydia treatment essential when empiric therapy is indicated 3