What is the treatment for possible gonorrhea exposure?

Treatment for Possible Gonorrhea Exposure

For possible gonorrhea exposure, treat empirically with ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days), which covers both gonorrhea and presumptive chlamydia coinfection. 1

Primary Treatment Regimen

• Ceftriaxone 250 mg IM in a single dose is the cornerstone of treatment, combined with concurrent therapy for chlamydia since coinfection rates are high and testing may not be immediately available 1, 2

• Add azithromycin 1 g orally as a single dose as the preferred second antimicrobial (preferred over doxycycline due to high tetracycline resistance rates) 1

• Alternatively, doxycycline 100 mg orally twice daily for 7 days can be used if azithromycin is contraindicated, though azithromycin is preferred 1

Site-Specific Considerations

• For pharyngeal exposure, the same dual therapy regimen (ceftriaxone 250 mg IM plus azithromycin 1 g orally) is recommended, as pharyngeal gonorrhea is more difficult to eradicate than urogenital infections 1, 3

• For rectal exposure, use the identical regimen as for urogenital exposure 1

Alternative Regimens (When Ceftriaxone Unavailable or Contraindicated)

• If ceftriaxone is not readily available: Use cefixime 400 mg orally plus azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days), with mandatory test-of-cure at 1 week 1, 4

• If severe cephalosporin allergy exists: Use azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week and infectious disease consultation 1, 5

• Spectinomycin 2 g IM is another alternative for urogenital and anorectal infections (98.2% cure rate), but it has only 52% efficacy against pharyngeal infections 1, 3

Critical Management Steps for Exposed Individuals

• Treat all sexual partners from the preceding 60 days, regardless of symptoms or test results 1

• Instruct patients to avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1

• If partner treatment cannot be ensured, consider expedited partner therapy by delivering cefixime 400 mg plus azithromycin 1 g to the partner (for heterosexual contacts only, not for MSM due to high risk of undiagnosed coexisting STDs) 1

Follow-Up and Testing

• Test-of-cure is NOT routinely recommended for patients treated with the recommended ceftriaxone-based dual therapy regimen 1

• Test-of-cure IS mandatory at 1 week for patients treated with alternative regimens (cefixime-based or azithromycin 2 g monotherapy), ideally using culture to allow antimicrobial susceptibility testing 1, 5

• Retest all patients at 3 months after treatment due to high reinfection rates (majority of post-treatment infections are reinfections, not treatment failures) 1

Special Populations

Pregnancy

• Pregnant women should receive ceftriaxone 250 mg IM plus azithromycin 1 g orally (avoid doxycycline and quinolones) 1

• If cephalosporin allergy exists, spectinomycin 2 g IM can be used, though with reduced efficacy for pharyngeal infections 1

HIV-Infected Patients

• Use the same treatment regimen as for HIV-negative patients 1

Important Clinical Pitfalls

• Never use fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) due to widespread resistance in the United States 1, 3

• Cefixime is no longer first-line therapy due to declining susceptibility; it should only be used when ceftriaxone is unavailable, and requires test-of-cure 1

• Do not use azithromycin monotherapy except in cases of severe cephalosporin allergy, as resistance is increasing (2.5% of isolates in 2014 showed reduced azithromycin susceptibility) 6

• For MSM, do not use expedited partner therapy due to high rates of coexisting undiagnosed STDs and HIV infection 1

Antimicrobial Resistance Concerns

• Dual therapy with two antimicrobials having different mechanisms of action is essential to slow emergence of cephalosporin resistance 1, 7

• Ceftriaxone resistance remains rare but surveillance shows concerning trends with elevated MICs, making continued monitoring critical 1, 6

• The 2020 CDC update increased the ceftriaxone dose recommendation to 500 mg IM for confirmed infections, though 250 mg remains appropriate for exposure treatment based on earlier guidelines 2