Treatment for Pharyngeal Gonorrhea and Chlamydia
For throat infections with gonorrhea and chlamydia, treat with ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1, 2, 3
Why This Specific Regimen
Pharyngeal gonorrhea is substantially harder to eradicate than urogenital or anorectal infections, making ceftriaxone the only reliably effective option for throat infections. 1, 3 The pharynx requires higher tissue penetration and sustained bactericidal levels that only ceftriaxone consistently achieves, with cure rates exceeding 90% for pharyngeal sites. 4
Key Components:
Ceftriaxone 500 mg IM is the cornerstone because it provides sustained, high bactericidal blood levels specifically needed for pharyngeal eradication. 2, 3, 5
Doxycycline 100 mg twice daily for 7 days addresses chlamydial coinfection, which although uncommon in the pharynx itself, frequently coexists at genital sites in 40-50% of gonorrhea cases. 1, 6, 7
Azithromycin is no longer preferred due to rapidly rising resistance rates (nearly 5% of isolates with elevated MICs by 2018) and concerns about antimicrobial stewardship. 2, 3
Critical Pitfalls to Avoid
Never use oral cefixime for pharyngeal infections - it has inferior efficacy compared to ceftriaxone for throat infections due to inadequate tissue penetration. 1, 6
Never use quinolones (ciprofloxacin, ofloxacin) - widespread resistance makes these completely ineffective. 1, 6, 7
Never use azithromycin 1g alone - only 93% efficacy for gonorrhea and insufficient as monotherapy. 1, 6
Spectinomycin is only 52% effective against pharyngeal gonorrhea and should be avoided if throat infection is suspected, even in cephalosporin-allergic patients. 4, 1, 6
Alternative Regimens (Only When Ceftriaxone Unavailable)
If ceftriaxone is truly unavailable:
- Cefixime 400 mg orally single dose PLUS doxycycline 100 mg twice daily for 7 days, but this requires mandatory test-of-cure at 1 week due to inferior pharyngeal efficacy. 1, 6
For severe cephalosporin allergy (extremely limited options):
Azithromycin 2g orally single dose with mandatory test-of-cure at 1 week, though this causes significant GI side effects in 35% of patients and has suboptimal efficacy. 1, 6
There are no recommended alternative therapies for pharyngeal gonorrhea in cephalosporin-allergic patients - consultation with infectious disease specialist is essential. 3
Special Populations
Pregnant women:
- Use ceftriaxone 500 mg IM single dose (safe in pregnancy). 6, 7
- Never use doxycycline, quinolones, or tetracyclines in pregnancy. 4, 6
- For chlamydia coverage: azithromycin 1g orally single dose or amoxicillin 500 mg three times daily for 7 days. 4, 6
HIV-infected patients:
Partner Management
All sexual partners from the preceding 60 days must be evaluated and treated with the same regimen, regardless of symptoms. 4, 1, 6, 7
Patients must avoid all sexual intercourse until therapy is completed and both patient and all partners are asymptomatic. 4, 1, 6
If partners' treatment cannot be ensured, expedited partner therapy may be considered. 1
Follow-Up Requirements
Routine test-of-cure is NOT needed for patients treated with the recommended ceftriaxone regimen unless symptoms persist. 4, 6, 7
Retest all patients at 3 months after treatment due to high reinfection risk (this is screening for reinfection, not treatment failure). 1, 7
If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing and consult infectious disease specialist. 4, 1, 7