What is the recommended treatment for gonorrhea in a 170-pound (77 kg) male?

Treatment for Gonorrhea in a 170 lb Male

Treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days (if chlamydial coinfection has not been excluded). 1

Primary Treatment Regimen

• The current CDC recommendation is ceftriaxone 500 mg IM once, which represents an increase from the previous 250 mg dose. 1
• This dose increase was implemented in 2020 to maintain efficacy against evolving resistance patterns while moving away from routine dual therapy with azithromycin. 1
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been ruled out, as co-infection occurs in 40-50% of gonorrhea cases. 2
• Azithromycin 1 g orally once can be substituted for doxycycline if compliance with a 7-day regimen is a concern, though doxycycline is now preferred due to rising azithromycin resistance. 1

Alternative Regimens (When Ceftriaxone Unavailable)

• If ceftriaxone is not available, use cefixime 400 mg orally once PLUS azithromycin 1 g orally once. 3, 2
• This oral alternative is less effective than ceftriaxone, particularly for pharyngeal infections (which have only 52-91% cure rates with oral cephalosporins versus 98-99% with ceftriaxone). 3, 2
• A test-of-cure is mandatory 1 week after treatment when using cefixime because of declining effectiveness due to rising minimum inhibitory concentrations. 3, 2

Severe Cephalosporin Allergy

• For patients with documented severe cephalosporin allergy (not just penicillin allergy), use azithromycin 2 g orally once. 3, 2
• This regimen requires a test-of-cure 1 week after treatment. 3, 2
• Azithromycin monotherapy has only 93% efficacy and should be avoided when other options exist. 2

Critical Considerations for This Patient

• Determine if the patient is a man who has sex with men (MSM), as this population requires ceftriaxone due to higher prevalence of resistant strains. 3, 2
• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are absolutely contraindicated due to widespread resistance and should never be used. 2, 4
• Ask about recent foreign travel or partners' travel history, as this also mandates ceftriaxone use. 5, 2
• Determine the site of infection—pharyngeal gonorrhea is significantly harder to eradicate and strongly favors ceftriaxone over oral alternatives. 2

Concurrent Testing and Partner Management

• Screen for syphilis with serology at the time of gonorrhea diagnosis. 3
• Test for HIV and other sexually transmitted infections. 4
• Evaluate and treat all sex partners from the preceding 60 days. 3, 2
• Instruct the patient to avoid sexual intercourse until both he and his partners complete therapy and are asymptomatic. 2

Follow-Up

• Patients treated with the recommended ceftriaxone regimen do not require a routine test-of-cure unless symptoms persist. 2
• Consider retesting at 3 months due to high reinfection rates (not treatment failure). 2
• If symptoms persist after treatment, perform culture with antimicrobial susceptibility testing and consult infectious disease. 2

Common Pitfalls to Avoid

• Never use azithromycin 1 g alone—it is insufficient for gonorrhea treatment with only 93% efficacy. 2
• Do not substitute oral cefixime for ceftriaxone in MSM, travelers, or pharyngeal infections without understanding the significantly lower cure rates. 3, 2
• The 170 lb (77 kg) weight does not require dose adjustment—all adult doses are standardized regardless of weight. 6
• Ensure concurrent chlamydia treatment is provided, as empiric coverage is essential given the extremely high co-infection rate. 2