Vancomycin is NOT Used to Treat Gonorrhea
Vancomycin has no role in the treatment of gonorrhea and should never be used for this indication. Vancomycin is a glycopeptide antibiotic that lacks activity against Neisseria gonorrhoeae and does not appear in any CDC treatment guidelines for gonococcal infections 1.
Current Recommended Treatment for First-Time Uncomplicated Gonorrhea
The only CDC-recommended first-line regimen is ceftriaxone 250 mg intramuscularly PLUS azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days). 1, 2
Why Combination Therapy is Mandatory
- Dual therapy addresses potential co-infection with Chlamydia trachomatis and helps prevent the emergence of antimicrobial resistance 1, 2
- Monotherapy with any agent is no longer recommended due to rising resistance patterns 1, 2
Alternative Regimens (When Ceftriaxone is Unavailable)
If ceftriaxone cannot be administered, cefixime 400 mg orally plus azithromycin 1 g orally may be used, but this requires mandatory test-of-cure at 1 week. 1, 2
Critical Limitations of Cefixime
- Provides lower and less sustained bactericidal levels than ceftriaxone, with cure rates of only 97.1-97.4% for urogenital/anorectal sites 2, 3
- Only 91% effective for pharyngeal gonorrhea, falling below the 95% threshold required for first-line therapy 2, 3
- Should never be used without azithromycin co-treatment 3
Non-Cephalosporin Alternatives (For True Cephalosporin Allergy)
For patients with documented cephalosporin allergy, gentamicin 240 mg intramuscularly plus azithromycin 2 g orally achieves 100% cure rates for urogenital gonorrhea. 4
- Gemifloxacin 320 mg orally plus azithromycin 2 g orally achieved 99.5% cure rates in clinical trials 4
- Both regimens cause significant gastrointestinal adverse events (35-40% of patients) which may limit routine use 5, 4
- Spectinomycin 2 g intramuscularly is an older alternative but is relatively ineffective against pharyngeal infection 1
Common Pitfalls to Avoid
- Never use quinolones (ciprofloxacin, ofloxacin, levofloxacin) - these were removed from CDC recommendations in 2007 due to widespread resistance 1
- Never use oral cephalosporins other than cefixime - cefuroxime achieves only 95.9% cure for urogenital sites and 56.9% for pharyngeal sites, both unacceptable 6
- Never use cefixime for pharyngeal infections - the 91% efficacy is inadequate 2, 3
- Never use azithromycin 2 g as monotherapy - while effective (98.9% cure rate), concerns about rapid resistance emergence preclude its use alone 5