What is the recommended management and treatment for a patient with a history of gonorrhea?

Gonorrhea: History, Physical Examination, and Management

Recommended Treatment

For uncomplicated gonorrhea of the cervix, urethra, rectum, or pharynx, treat with ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose. 1

This dual therapy recommendation is based on rising antimicrobial resistance patterns and addresses possible chlamydial coinfection, which occurs in 40-50% of gonorrhea cases. 1

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Clinical History: Key Elements to Obtain

• Sexual history from the preceding 60 days, including number of partners, types of sexual contact (genital, oral, anal), and partner symptoms 2, 3
• Symptoms by anatomic site: urethral discharge, dysuria, vaginal discharge, rectal pain/discharge, sore throat, or joint pain/swelling 4
• Recent travel history, particularly to areas with quinolone-resistant N. gonorrhoeae 1
• Previous sexually transmitted infections and treatment history 3
• Pregnancy status in women of childbearing age 5
• Medication allergies, particularly to cephalosporins 1

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Physical Examination: Pertinent Findings

• Genital examination: urethral discharge, cervical discharge, cervical motion tenderness, adnexal tenderness 3
• Pharyngeal examination: erythema, exudate (though pharyngeal gonorrhea is often asymptomatic) 1
• Rectal examination: discharge, erythema, tenderness 3
• Joint examination: effusion, warmth, erythema, limited range of motion (for disseminated gonococcal infection) 4
• Skin examination: pustular or vesiculopustular lesions on extremities (for disseminated infection) 4

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Treatment Regimens by Clinical Scenario

Uncomplicated Urogenital, Rectal, or Pharyngeal Gonorrhea

Primary regimen:

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose 1
• Azithromycin is preferred over doxycycline due to single-dose convenience and higher compliance 1

Alternative regimen if ceftriaxone unavailable:

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 2, 6
• Requires test-of-cure at 1 week due to declining cefixime effectiveness 2, 1

Alternative for severe cephalosporin allergy:

• Azithromycin 2 g orally single dose 2, 1
• Requires test-of-cure at 1 week 2

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Disseminated Gonococcal Infection (Arthritis, Dermatitis)

Initial parenteral therapy:

• Ceftriaxone 1 g IV or IM every 24 hours 4
• Continue until 24-48 hours of clinical improvement 4

Transition to oral therapy:

• Cefixime 400 mg orally twice daily to complete at least 1 week total therapy 4
• Hospitalization recommended for initial therapy 4

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Special Populations

Pregnant women:

• Ceftriaxone 250 mg IM PLUS azithromycin 1 g orally (same as non-pregnant) 1, 5
• Avoid quinolones and tetracyclines 3
• Retest in third trimester if treated earlier in pregnancy 5

Men who have sex with men (MSM):

• Only use ceftriaxone-based regimens due to higher prevalence of resistant strains 1
• Never use quinolones in this population 1, 4

Patients with recent foreign travel:

• Only use ceftriaxone-based regimens 1

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Critical Management Considerations

Partner Management

• All sex partners from the preceding 60 days must be evaluated and treated 2, 3, 1
• If last sexual contact was >60 days before diagnosis, treat the most recent partner 3
• Consider expedited partner therapy with cefixime 400 mg plus azithromycin 1 g if partner cannot be linked to care 2, 1
• Patients must abstain from sexual intercourse until therapy completed and both partners asymptomatic 3, 1

Follow-Up and Test-of-Cure

• No test-of-cure needed for patients treated with recommended ceftriaxone-based regimens 3, 1
• Test-of-cure required at 1 week for patients treated with alternative regimens (cefixime alone or azithromycin 2g) 2, 1
• Retest all patients at 3 months due to high reinfection risk (not test-of-cure, but screening for reinfection) 3, 1, 5

Treatment Failure

• Culture specimens from all infected sites with antimicrobial susceptibility testing 2, 1
• Consult infectious disease specialist 2
• Report to CDC through local/state health department within 24 hours 2
• Retreat with ceftriaxone 250 mg IM plus azithromycin 2 g orally 2

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Important Clinical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance 1, 7
• Never use azithromycin 1 g alone for gonorrhea—only 93% efficacy and promotes resistance 1
• Pharyngeal gonorrhea is harder to eradicate than urogenital infections; ceftriaxone has superior efficacy for pharyngeal sites compared to oral alternatives 1
• Failure to treat partners is the most common cause of reinfection and continued transmission 1
• Do not substitute tablets/capsules for suspension when treating otitis media in children, as suspension achieves higher peak levels 6

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Antimicrobial Resistance Considerations

• Dual therapy with two antimicrobials having different mechanisms of action improves efficacy and potentially delays emergence of cephalosporin resistance 1, 7
• Rising cefixime minimum inhibitory concentrations (MICs) have resulted in declining effectiveness 1
• Ceftriaxone resistance remains rare but surveillance is essential 7
• Maintain culture capacity for antimicrobial susceptibility testing despite widespread NAAT use 2

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Diagnostic Testing

• Nucleic acid amplification testing (NAAT) is preferred for diagnosis from genital, rectal, and pharyngeal sites 2
• Culture with antimicrobial susceptibility testing required for treatment failures and suspected resistant cases 2, 1
• Test for concurrent chlamydia in all patients, as coinfection occurs in 40-50% of cases 3, 1
• Perform serologic testing for syphilis in all patients with sexually transmitted urethritis or cervicitis 8