What is the recommended treatment for a suspected case of gonorrhoea?

Treatment for Suspected Gonorrhea

For suspected uncomplicated gonorrhea, prescribe ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days (to cover possible chlamydial coinfection). 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the current CDC-recommended first-line treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 2
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded, which is the standard approach in suspected cases 1, 2
• This dual therapy addresses the extremely high coinfection rate (40-50% of gonorrhea patients also have chlamydia) 1

Rationale for Current Dosing

• The CDC updated from 250 mg to 500 mg ceftriaxone in 2020 to maintain efficacy against evolving resistance patterns 2
• Doxycycline is now preferred over azithromycin for chlamydial coverage due to antimicrobial stewardship concerns and rising azithromycin resistance 2
• Azithromycin 1 g as the second agent (the older recommendation) is no longer preferred due to resistance concerns, though it remains an alternative 1

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not readily available:

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 3, 1
• Mandatory test-of-cure at 1 week is required with this regimen 3, 1
• Note: Cefixime has declining effectiveness due to rising minimum inhibitory concentrations 1

Severe Cephalosporin Allergy

If the patient has documented severe cephalosporin allergy:

• Azithromycin 2 g orally single dose 3, 1
• Mandatory test-of-cure at 1 week 3, 1
• Warning: This regimen has lower efficacy (only 93%) and high gastrointestinal side effects 1, 4
• Alternative: Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally single dose (100% cure rate in clinical trials) 3, 5

Critical Site-Specific Considerations

Pharyngeal Infections

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital infections 1, 6
• Ceftriaxone is the only reliably effective treatment for pharyngeal infections 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 3
• Gentamicin also has poor pharyngeal efficacy (only 20% cure rate in one study) 3

Rectal Infections

• Standard ceftriaxone regimens are effective for rectal infections 3, 6
• At least one case of symptomatic rectal infection failing treatment has been reported 3

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 3, 1
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 3, 1
• Patients must avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1
• Consider expedited partner therapy (cefixime 400 mg + azithromycin 1 g delivered to partner) if partner cannot be linked to timely evaluation 3

Follow-Up Requirements

• No routine test-of-cure needed if treated with recommended ceftriaxone regimen and symptoms resolve 1, 6
• Mandatory test-of-cure at 1 week for patients receiving cefixime or azithromycin monotherapy 1
• Evaluate patients with persistent symptoms by culture with antimicrobial susceptibility testing 3, 1
• Consider retesting all patients at 3 months due to high reinfection risk 1

Treatment Failure Management

If treatment failure is suspected:

• 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
• Recommended salvage regimens include: gentamicin 240 mg IM PLUS azithromycin 2 g orally or ertapenem 1 g IM for 3 days 3

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite historical 99.8% cure rates 1, 6
• Never use azithromycin 1 g alone for gonorrhea treatment (only 93% efficacy) 1
• Never substitute tablets/capsules for suspension when treating otitis media, as suspension achieves higher peak levels 7
• Never use spectinomycin for pharyngeal infections (only 52% effective) 3

Special Populations

Pregnancy

• Use ceftriaxone (preferred cephalosporin) PLUS azithromycin 1 g orally 3, 1
• Never use quinolones or tetracyclines in pregnancy 3, 1
• If cephalosporin allergy: spectinomycin 2 g IM single dose (but avoid if pharyngeal infection suspected) 3

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 3