What is the recommended treatment for oral gonorrhea in a male?

Treatment for Oral Gonorrhea in Males

For oral (pharyngeal) gonorrhea in males, treat with ceftriaxone 500 mg intramuscularly as a single dose plus azithromycin 1 g orally as a single dose. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose is the recommended first-line treatment for pharyngeal gonorrhea 1, 2
• The dual therapy approach addresses both antimicrobial resistance concerns and potential chlamydial co-infection, which occurs in 40-50% of gonorrhea cases 1
• Azithromycin is strongly preferred over doxycycline due to single-dose convenience, better compliance, and substantially lower gonococcal resistance to azithromycin compared to tetracyclines 3, 1

Critical Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 4
• Ceftriaxone demonstrates superior efficacy for pharyngeal infections compared to all oral alternatives 1
• Cefixime (oral cephalosporin) has limited efficacy for pharyngeal gonorrhea and should be avoided for this site 3
• The higher 500 mg dose of ceftriaxone is now recommended (updated from previous 250 mg dosing) to ensure adequate treatment efficacy 2

Alternative Regimens (When Ceftriaxone Unavailable)

• If ceftriaxone is not available: Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose, with mandatory test-of-cure at 1 week 3, 1

  • However, cefixime has poor pharyngeal efficacy and this regimen is suboptimal for oral gonorrhea 3, 1

• For severe cephalosporin allergy: Azithromycin 2 g orally single dose with mandatory test-of-cure at 1 week 3, 1

  • This regimen has lower efficacy (only 93%) and high gastrointestinal side effects 1, 5
  • Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 1
  • Gentamicin also has poor pharyngeal efficacy (only 20% cure rate) and should be avoided 1, 6

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance 1, 7
• Never use azithromycin 1 g alone as monotherapy—it has insufficient efficacy (only 93% cure rate) 1
• Never substitute oral cefixime for ceftriaxone when treating pharyngeal infections—ceftriaxone is the only reliably effective treatment for pharyngeal gonorrhea 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 3, 1, 4
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 1
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 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 alternative regimens (cefixime or azithromycin monotherapy) 3, 1
• Consider retesting all patients at 3 months after treatment due to high risk of reinfection 1
• Screen for syphilis with serology at the time of gonorrhea diagnosis 4
• Test for other sexually transmitted infections including HIV 7

Treatment Failure Management

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