Gonorrhea Treatment
The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, combined with azithromycin 1 g orally as a single dose for dual therapy. 1
Primary Treatment Regimen
Ceftriaxone 500 mg IM once PLUS azithromycin 1 g orally once is the first-line treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx. 1, 2
The dual therapy approach addresses rising antimicrobial resistance patterns and improves treatment efficacy while potentially delaying emergence of cephalosporin resistance. 1
Azithromycin is strongly preferred over doxycycline as the second agent due to single-dose convenience, better compliance, and substantially lower rates of gonococcal resistance to azithromycin compared to tetracyclines. 1
Co-infection with Chlamydia trachomatis occurs in 40-50% of gonorrhea cases, making dual therapy essential. 1
Alternative Regimens When Ceftriaxone Unavailable
If ceftriaxone is not available, use cefixime 400 mg orally once PLUS azithromycin 1 g orally once, but this regimen requires mandatory test-of-cure at 1 week post-treatment. 3, 1
Cefixime is significantly less effective than ceftriaxone, particularly for pharyngeal infections (which are inherently more difficult to eradicate), and should only be used when ceftriaxone cannot be obtained. 3, 1, 4
For patients with severe cephalosporin allergy, azithromycin 2 g orally once is recommended, with mandatory test-of-cure at 1 week, though this has lower efficacy and higher gastrointestinal side effects. 3, 1
Critical Pitfalls to Avoid
Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance. 1
Never use azithromycin 1 g alone—it has insufficient efficacy with only 93% cure rate. 1
Never use quinolones in men who have sex with men (MSM) due to higher prevalence of resistant strains in this population. 3
Special Populations
For MSM, use only ceftriaxone (not cefixime or other alternatives) due to higher prevalence of resistant strains. 3, 1
For pregnant women, ceftriaxone is the preferred treatment; quinolones and tetracyclines are absolutely contraindicated. 3, 1
For patients with history of recent foreign travel, use only ceftriaxone due to increased risk of resistant strains. 1
Site-Specific Considerations
Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 1
Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives and is strongly preferred over cefixime for pharyngeal sites. 1
Partner Management
Evaluate and treat all sex partners from the preceding 60 days. 3, 1
If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner. 3
Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic. 1
Consider expedited partner therapy (EPT) if partners' treatment cannot be ensured—EPT reduces retreatment rates by 45%. 1
Follow-Up and Testing
Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist. 1
Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy. 1
Screen for syphilis with serology at the time of gonorrhea diagnosis. 3
Consider retesting all patients at 3 months after treatment due to high risk of reinfection (approximately 10% retreatment rate within 2 years). 1
Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae with antimicrobial susceptibility testing. 1