Treatment of Oropharyngeal Gonorrhea

Treat with ceftriaxone 500 mg IM as a single dose PLUS azithromycin 1 g orally as a single dose for oropharyngeal gonorrhea. 1

Primary Treatment Regimen

Ceftriaxone 500 mg IM single dose is the recommended first-line treatment for oropharyngeal gonorrhea, representing an update from the previous 250 mg dose 1
Add azithromycin 1 g orally single dose to cover potential chlamydial coinfection at genital sites, even though pharyngeal chlamydial coinfection is rare 2, 3, 4
If chlamydial infection has been definitively excluded, doxycycline 100 mg orally twice daily for 7 days can be substituted for azithromycin 1

Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, requiring regimens that reliably cure >90% of infections 2, 3
The pharynx serves as a critical reservoir for antimicrobial resistance development through DNA exchange with commensal Neisseria species, and infections can persist asymptomatically for up to 16 weeks 2
Ceftriaxone achieves variable pharmacokinetics in pharyngeal tissue, with salivary and tonsillar levels differing substantially from serum concentrations 2
Most documented ceftriaxone treatment failures involve pharyngeal infections, not urogenital sites 2

Never use spectinomycin for pharyngeal gonorrhea - it has only 52% efficacy at this site and is completely unreliable 3, 4, 5
Never use gentamicin for pharyngeal infections - one study showed only 2 of 10 patients (20%) with pharyngeal gonorrhea were cured with gentamicin 2, 4
Never use azithromycin 1 g alone - it has insufficient efficacy (only 93%) for gonorrhea treatment 2, 3, 4
Never use quinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite their historical 99.8% cure rate 4
Avoid oral cephalosporins (cefixime, cefpodoxime) for pharyngeal infections - cefpodoxime has only 78.9% efficacy and cefuroxime axetil has unacceptable 56.9% efficacy for pharyngeal gonorrhea 2

This patient requires Hepatitis A vaccination - they are Hep A IgG negative, indicating no immunity [@General Medicine Knowledge@]
No Hepatitis B vaccination is needed - the patient has Hep B surface antibody positive, indicating immunity (either from prior vaccination or resolved infection) [@General Medicine Knowledge@]
Administer Hepatitis A vaccine series (2 doses, 6-12 months apart) at this visit or schedule follow-up for vaccination [@General Medicine Knowledge@]

Patients treated with the recommended ceftriaxone 500 mg IM plus azithromycin regimen do not require routine test of cure unless symptoms persist 2, 3
If symptoms persist after treatment, obtain culture for N. gonorrhoeae with antimicrobial susceptibility testing 2, 3
Consider retesting at 3 months due to high risk of reinfection (not treatment failure) 4

Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen for both gonorrhea and chlamydia 2, 3, 4
Instruct the patient to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 2, 3
If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent sexual partner 2

If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately 4
Report the case to local public health officials within 24 hours 4
Consult an infectious disease specialist 4
For confirmed treatment failure, consider gentamicin 240 mg IM plus azithromycin 2 g orally (if azithromycin-susceptible), or ertapenem 1 g IM daily for 3 days 2, 4

If ceftriaxone is unavailable, use cefixime 400 mg orally single dose PLUS azithromycin 1 g orally, but this requires mandatory test-of-cure at 1 week due to inferior efficacy for pharyngeal infections 4
For severe cephalosporin allergy, azithromycin 2 g orally single dose can be used, but has lower efficacy (93%), high gastrointestinal side effects, and requires mandatory test-of-cure at 1 week 4, 6