What is the appropriate treatment for a sore throat potentially caused by a sexually transmitted infection (STI) after performing oral sex?

Treatment of Sore Throat After Oral Sex

Treat empirically for both gonorrhea and chlamydia with ceftriaxone 125 mg IM once PLUS doxycycline 100 mg orally twice daily for 7 days, as pharyngeal gonorrhea is notoriously difficult to eradicate and requires this dual therapy approach. 1

Immediate Empiric Treatment

The pharynx is a common site for sexually transmitted infections following oral sex, with Neisseria gonorrhoeae and Chlamydia trachomatis being the primary pathogens of concern. 1 Pharyngeal infections are more difficult to eradicate than urogenital infections, requiring specific antimicrobial regimens that achieve >90% cure rates. 1

Recommended first-line regimen:

• Ceftriaxone 125 mg IM as a single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1

This dual therapy addresses both gonorrhea (which is harder to treat in the pharynx) and presumptive chlamydial coinfection. 1 Although chlamydial pharyngeal coinfection is uncommon, genital site coinfection occurs frequently enough to warrant empiric coverage. 1

Alternative Regimens

For patients with cephalosporin allergy:

• Spectinomycin is an option, but it is only 52% effective against pharyngeal gonorrhea 1
• If spectinomycin is used, obtain a pharyngeal culture 3-5 days post-treatment to verify eradication 1

Geographic considerations for quinolones:

• Ciprofloxacin 500 mg orally once was previously acceptable 1
• However, quinolone-resistant N. gonorrhoeae (QRNG) is now widespread, particularly in men who have sex with men, patients with recent foreign travel (especially Asia and Pacific regions), and infections acquired in California or Hawaii 1
• Do not use quinolones if any of these risk factors are present 1

Diagnostic Testing

While empiric treatment should be initiated immediately, obtain:

• Pharyngeal culture or NAAT for N. gonorrhoeae and C. trachomatis 1
• Note that Gram stain of pharyngeal specimens is insufficient and not recommended 1
• Test for syphilis and HIV 1
• Consider testing for other STIs including herpes simplex virus if vesicles are present 1, 2

Critical Management Points

Partner notification and treatment:

• All sexual partners within the past 60 days must be evaluated and treated for both gonorrhea and chlamydia 1
• If the patient's last sexual contact was >60 days before symptom onset, treat the most recent partner 1

Sexual abstinence:

• Instruct the patient to avoid all sexual contact until therapy is completed and both patient and partners are asymptomatic 1

Follow-up strategy:

• Test-of-cure is not routinely needed for patients treated with recommended regimens 1
• However, consider retesting at 3 months due to high reinfection rates 1
• If symptoms persist after treatment, perform culture with antimicrobial susceptibility testing 1

Common Pitfalls to Avoid

Do not rely on clinical examination alone to distinguish bacterial from viral pharyngitis in this context—the sexual exposure history mandates empiric STI treatment regardless of throat appearance. 2

Do not use azithromycin monotherapy (even at 2g dose) due to concerns about rapid emergence of antimicrobial resistance in N. gonorrhoeae. 1

Do not skip the IM ceftriaxone in favor of oral-only regimens—pharyngeal gonorrhea requires the higher tissue levels achieved with parenteral cephalosporins. 1

Do not forget that this exposure may mask incubating syphilis—all patients require syphilis serology at baseline. 3