What is the recommended treatment for gonorrhoea?

Gonorrhea Treatment

The recommended treatment for gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus treatment for presumptive chlamydial coinfection with doxycycline 100 mg orally twice daily for 7 days (or azithromycin 1 g orally as a single dose if doxycycline is contraindicated). 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the first-line treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 1
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded 1
• The dose increase from 250 mg to 500 mg reflects updated CDC guidance from 2020 to maintain efficacy against evolving resistance patterns 1
• Dual therapy addresses the 40-50% coinfection rate with Chlamydia trachomatis 2

Alternative Regimens When Ceftriaxone Is Unavailable

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 2
• Mandatory test-of-cure at 1 week is required with cefixime due to declining effectiveness related to rising minimum inhibitory concentrations 2
• This regimen is less effective than ceftriaxone, particularly for pharyngeal infections 2

Severe Cephalosporin Allergy

• Azithromycin 2 g orally single dose is the only option for patients with severe cephalosporin allergy 2
• This regimen has only 93% efficacy and causes significant gastrointestinal side effects 2, 3
• Mandatory test-of-cure at 1 week is required 2
• Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally is an alternative, but has poor pharyngeal efficacy (only 20% cure rate) 2, 4

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 2
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections 2
• Gentamicin showed only 80% clearance for pharyngeal infections compared to 96% with ceftriaxone 4
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 2

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally 2, 5
• Never use quinolones or tetracyclines in pregnancy 2
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester 5

Neonates

• Ceftriaxone is contraindicated in premature neonates and in neonates ≤28 days requiring calcium-containing IV solutions 6
• Intravenous doses must be given over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 6

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance 2, 1
• Never use azithromycin 1 g alone—it has insufficient efficacy (only 93% cure rate) 2
• Never use diluents containing calcium with ceftriaxone due to precipitation risk 6
• Do not use patient-delivered partner therapy for men who have sex with men due to high risk of undiagnosed coexisting STDs or HIV 2

Follow-Up and Test-of-Cure

• Patients treated with recommended ceftriaxone regimens do not need routine test-of-cure 2, 5
• Patients with persistent symptoms should have culture with antimicrobial susceptibility testing 2
• All patients should be retested 3 months after treatment due to high reinfection rates (not treatment failure) 2, 5

Treatment Failure Management

• If treatment failure occurs, obtain specimens for culture and antimicrobial susceptibility testing immediately 2
• Report the case to local public health officials within 24 hours 2
• Consult an infectious disease specialist 2
• Salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days 2
• Most ceftriaxone treatment failures involve pharyngeal sites, not urogenital sites 2

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated 2
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 2
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 2
• Expedited partner therapy with cefixime 400 mg plus azithromycin 1 g may be considered for heterosexual partners when direct evaluation is not feasible 7

Antimicrobial Resistance Context

• The shift from dual therapy with azithromycin to doxycycline reflects antimicrobial stewardship concerns and increasing azithromycin resistance 1
• Ceftriaxone resistance remains rare but continued surveillance is essential 1
• N. gonorrhoeae has developed resistance to sulfonamides, tetracyclines, penicillins, and quinolones over time 5