Ciprofloxacin Should NOT Be Used for Gonorrhea Treatment in Current Practice
Ciprofloxacin is no longer recommended for gonorrhea treatment due to widespread quinolone resistance, and ceftriaxone remains the first-line therapy. 1
Current Treatment Recommendations
The CDC explicitly states that quinolones, including ciprofloxacin, should not be used for gonorrhea treatment due to widespread quinolone-resistant N. gonorrhoeae (QRNG). 1 This resistance is particularly common among men who have sex with men, in certain geographic regions, and in infections acquired during international travel. 1
First-Line Therapy
- Ceftriaxone 250 mg IM as a single dose is the recommended treatment for gonorrhea. 1
- This should be combined with treatment for presumptive chlamydia co-infection (azithromycin 1g orally single dose or doxycycline 100mg orally twice daily for 7 days). 1
Historical Context and Resistance Evolution
While ciprofloxacin was once a recommended first-line agent in the 1990s (500 mg orally as a single dose), 2 the landscape has dramatically changed:
- In 1993, ciprofloxacin 500 mg cured >95% of genital/anal infections and ≥90% of pharyngeal infections when strains were susceptible. 2
- By 2002 in the UK, ciprofloxacin resistance had risen to 9.8%, exceeding the threshold for acceptable first-line therapy. 3
- Recent data from Poland (2012-2013) showed that >61% of N. gonorrhoeae strains were ciprofloxacin-resistant. 4
When Ciprofloxacin Could Theoretically Be Considered
Ciprofloxacin can only be effective if the strain has an MIC <0.125 μg/mL, which requires molecular susceptibility testing. 2, 5
Efficacy by MIC Level:
- MIC <0.125 μg/mL: 99.2% cure rate (including pharyngeal infections at 92-100%) 2, 5
- MIC 0.125-0.5 μg/mL: 76.3% cure rate 5
- MIC ≥1 μg/mL: Only 30.1% cure rate 5
Critical Limitations:
- Molecular assays to predict ciprofloxacin susceptibility are not widely available in clinical practice. 5
- Without documented susceptibility testing showing MIC <0.125 μg/mL, ciprofloxacin should never be used. 2, 5
- The pharynx is a key site for antimicrobial resistance emergence, making treatment failures particularly problematic. 2
Important Clinical Pitfalls
Do Not Use Ciprofloxacin Empirically
- Empiric ciprofloxacin use for suspected gonorrhea is contraindicated and represents substandard care. 1
- Treatment failures contribute to ongoing transmission and resistance development. 2
Syphilis Considerations
- Ciprofloxacin is not effective against syphilis, unlike ceftriaxone which may abort incubating syphilis. 6
- All patients with gonorrhea require syphilis testing at diagnosis and follow-up serologic testing after three months if treated with ciprofloxacin. 6
Contraindications
- Ciprofloxacin is contraindicated in pregnant women, nursing mothers, and persons ≤17 years of age. 2
Bottom Line for Clinical Practice
Use ceftriaxone 250 mg IM as first-line therapy for all gonorrhea cases. 1 Ciprofloxacin should only be considered in the rare circumstance where molecular resistance testing confirms an MIC <0.125 μg/mL and ceftriaxone is unavailable or contraindicated. 2, 5 In real-world practice, this means ciprofloxacin has essentially no role in contemporary gonorrhea management. 1