What is the recommended treatment for gonorrhea?

Treatment for Gonorrhea

Primary Recommendation

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 250 mg intramuscularly in a single dose PLUS azithromycin 1 g orally in a single dose. 1

This dual therapy regimen should be administered together on the same day, preferably simultaneously and under direct observation. 2, 3

Rationale for Dual Therapy

• Dual therapy is essential due to rising antibiotic resistance patterns, which necessitate combination therapy with two antimicrobials having different mechanisms of action to improve treatment efficacy and potentially delay emergence and spread of cephalosporin resistance. 1

• The dual regimen also addresses the extremely common co-infection with Chlamydia trachomatis, which occurs in 40-50% of gonorrhea patients. 1

• Azithromycin is preferred over doxycycline due to the convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin. 1

• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy, making monotherapy unacceptable. 1

Alternative Regimens

When Ceftriaxone is Unavailable

• Use cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose. 1, 4

• A test-of-cure must be performed 1 week after treatment with this regimen due to declining effectiveness of cefixime for urogenital gonorrhea related to rising MICs. 1

• Cefixime has inferior efficacy compared to ceftriaxone, particularly for pharyngeal infections, and should be considered second-line. 1

For Severe Cephalosporin Allergy

• Azithromycin 2 g orally in a single dose is recommended, with a test-of-cure performed 1 week after treatment. 1

• Spectinomycin 2 g intramuscularly in a single dose is an alternative, though it has poor efficacy (only 52%) against pharyngeal gonorrhea. 1

Critical Antimicrobial Resistance Considerations

• Quinolones (ciprofloxacin, ofloxacin) are no longer recommended for gonorrhea treatment due to widespread resistance. 1, 5

• Never use quinolones for infections in men who have sex with men (MSM) or in patients with history of recent foreign travel, due to high prevalence of resistant strains. 1

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains in this population. 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 all alternative treatments and is strongly preferred over cefixime for pharyngeal infections. 1

• For otitis media caused by gonorrhea, the suspension formulation should be used as it results in higher peak blood levels than tablets when administered at the same dose. 4

Special Populations

Pregnancy

• Pregnant women infected with N. gonorrhoeae should be treated with the recommended dual therapy of ceftriaxone plus azithromycin. 1, 2

• Pregnant women should not be treated with quinolones or tetracyclines. 5, 1

• Ceftriaxone is the preferred cephalosporin in pregnancy. 1

• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated. 2

Partner Management

• All sex partners from the preceding 60 days should be evaluated and treated for both N. gonorrhoeae and C. trachomatis. 1

• Patients should avoid sexual intercourse until therapy is completed and both patient and partner(s) are asymptomatic. 1

• If partners' treatment cannot be ensured, expedited partner therapy may be considered. 1

Follow-Up and Test-of-Cure

• Patients with uncomplicated gonorrhea treated with the recommended ceftriaxone plus azithromycin regimen do not need a test-of-cure. 1, 2

• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility. 1

• All patients should be retested 3 months after treatment due to high risk of reinfection (most infections detected after treatment represent reinfection rather than treatment failure). 1, 2

Treatment Failure Management

• For treatment failure, culture relevant clinical specimens and perform antimicrobial susceptibility testing. 1

• Consult an infectious disease specialist for cases of treatment failure. 1

• Alternative regimens for treatment failure include azithromycin 2 g orally plus gentamicin 240 mg intramuscularly, spectinomycin 2 g intramuscularly plus azithromycin 2 g orally, and ertapenem 1 g intramuscularly for 3 days. 6

Common Pitfalls to Avoid

• Never substitute oral cephalosporins or tablets for suspension formulations in treating pharyngeal infections or otitis media, as bioavailability and efficacy differ significantly. 1, 4

• Do not use monotherapy with any agent, as dual therapy is mandatory for all gonorrhea treatment. 1

• Do not assume treatment success without addressing partner treatment, as reinfection rates are extremely high. 1

• Ensure all orders specifying doses in milliliters include concentration specifications, as cefixime suspension is available in two different concentrations (100 mg/5 mL and 200 mg/5 mL). 4