Treatment for Gonorrhoea
Primary Recommendation
The first-line treatment for uncomplicated gonorrhoea is ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose. 1, 2
This dual therapy approach is essential for several critical reasons:
- Dual therapy addresses rising antimicrobial resistance by combining two antimicrobials with different mechanisms of action, which improves treatment efficacy and potentially delays emergence of cephalosporin resistance 1, 2
- Co-infection with Chlamydia trachomatis occurs in 40-50% of gonorrhoea patients, making presumptive treatment for both organisms essential 1, 2
- Azithromycin is strongly preferred over doxycycline due to the convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 1
Site-Specific Considerations
Pharyngeal gonorrhoea requires special attention as it is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2:
- Ceftriaxone has superior efficacy for pharyngeal infections compared to all alternative treatments 1
- Most cases of ceftriaxone treatment failure involve the pharynx, not urogenital sites 3
- Both spectinomycin and gentamicin have poor efficacy in the pharynx—one study was stopped early because only 2 of 10 individuals with pharyngeal gonorrhoea treated with gentamicin were cured 3
Alternative Regimens (When Ceftriaxone Unavailable)
If ceftriaxone is not available:
- Cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose 1, 2, 4
- Mandatory test-of-cure must be performed 1 week after treatment with this regimen due to declining effectiveness of cefixime related to rising MICs 1, 2
Severe Cephalosporin Allergy
For patients with severe cephalosporin allergy:
- Azithromycin 2 g orally as a single dose 1
- Mandatory test-of-cure at 1 week is required due to lower efficacy (only 93% cure rate) and higher gastrointestinal side effects 1
Critical Pitfalls to Avoid
- Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhoea treatment due to widespread resistance, despite their historical effectiveness 1, 2, 5
- Never use azithromycin 1 g alone as it has insufficient efficacy with only 93% cure rate 1
- Never substitute oral cefixime for ceftriaxone in pharyngeal infections—ceftriaxone is strongly preferred due to superior efficacy 1
Special Populations
Pregnant women:
- Should receive the standard dual therapy of ceftriaxone plus azithromycin 2
- Quinolones and tetracyclines are absolutely contraindicated in pregnancy 2
Men who have sex with men (MSM):
- Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains in this population 1, 2
Treatment Failure Management
If treatment failure occurs:
- Obtain specimens for culture and antimicrobial susceptibility testing immediately 3, 1
- Report the case to local public health officials within 24 hours 3
- Consult an infectious disease specialist 3, 1
For suspected ceftriaxone treatment failure, recommended regimens include:
- Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally (single dose) 3, 2
- Spectinomycin 2 g intramuscularly PLUS azithromycin 2 g orally 3, 2
- Ertapenem 1 g intramuscularly for 3 days 3, 2
Note that gentamicin/azithromycin achieved 100% microbiological cure in urogenital infections and cured 10 of 10 pharyngeal infections in clinical trials, though gastrointestinal adverse events were common 6.
Partner Management and Follow-Up
- All sex partners from the preceding 60 days must be evaluated and treated 1
- Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
- Patients treated with recommended ceftriaxone plus azithromycin regimen do not need routine test-of-cure unless symptoms persist 1, 2
- Consider retesting all patients 3 months after treatment due to high risk of reinfection (retreatment rates of approximately 10% within 2 years) 1, 7