What is the recommended empiric treatment for Gonorrhea (GC) and Chlamydia after exposure?

Empiric Treatment for Gonorrhea and Chlamydia After Exposure

For empiric treatment after GC/chlamydia exposure, administer ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1

Rationale for Dual Therapy

This dual-drug regimen is essential because:

• Co-infection rates are extremely high (40-50%), making presumptive treatment for both organisms mandatory when empiric therapy is indicated 1, 2
• Ceftriaxone provides reliable coverage for gonorrhea at all anatomic sites, including pharyngeal infections which are significantly harder to eradicate 1, 3
• Doxycycline ensures adequate chlamydia treatment with proven efficacy 4, 1
• The 2020 CDC update increased ceftriaxone dosing from 250 mg to 500 mg based on antimicrobial stewardship principles and evolving resistance patterns 5, 6

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Use cefixime 400 mg orally as a single dose PLUS doxycycline 100 mg twice daily for 7 days 1
• Critical caveat: This regimen has inferior efficacy and requires mandatory test-of-cure at 1 week 1, 2
• Never use cefixime for pharyngeal exposure—it has only 93% efficacy for throat infections 3

For severe cephalosporin allergy:

• Azithromycin 2 g orally as a single dose can be used 1, 2
• Major limitations: Only 93% efficacy, causes GI side effects in 35% of patients, and requires test-of-cure at 1 week 1, 2

Critical Pitfalls to Avoid

Never use these regimens:

• Quinolones (ciprofloxacin, ofloxacin): Widespread resistance makes them completely ineffective 1, 2, 3
• Azithromycin 1 g alone: Insufficient for gonorrhea with only 93% efficacy 1, 2
• Spectinomycin for pharyngeal exposure: Only 52% effective for throat infections 1, 2

Special Population: Pregnancy

For pregnant patients:

• Use ceftriaxone 500 mg IM single dose (safe in pregnancy) 1, 3
• Never use doxycycline, quinolones, or tetracyclines 1, 3, 7
• For chlamydia coverage: azithromycin 1 g orally single dose OR amoxicillin 500 mg three times daily for 7 days 1, 3

Partner Management

All sexual partners from the preceding 60 days must be:

• Evaluated and treated with the same dual therapy regimen, regardless of symptoms 1, 2, 3
• This prevents reinfection and breaks the transmission chain 4

Sexual abstinence requirements:

• Patients must avoid all sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 4
• Continue abstinence until both patient and all partners complete treatment and are asymptomatic 1, 3

Follow-Up and Monitoring

Test-of-cure is NOT routinely needed for patients treated with the recommended ceftriaxone + doxycycline regimen unless symptoms persist 1, 3

However:

• Retest all patients at 3 months after treatment due to high reinfection risk (20-30%) 1, 3
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing and consult infectious disease specialist 2, 3

Site-Specific Considerations

Pharyngeal infections require special attention:

• Pharyngeal gonorrhea is substantially harder to eradicate than urogenital or anorectal infections 1, 2, 3
• Ceftriaxone 500 mg IM is the only reliably effective treatment for throat infections, achieving sustained bactericidal levels that oral alternatives cannot match 3
• This is why ceftriaxone is strongly preferred over all oral alternatives when pharyngeal exposure is possible 2, 3

Dosing Details

Ceftriaxone: 500 mg IM single dose (for patients <150 kg/331 lbs) 5, 8, 6

Doxycycline: 100 mg orally twice daily for 7 days 4, 7, 5

• Administer with adequate fluids to reduce esophageal irritation risk 7
• Can be given with food or milk if gastric irritation occurs 7

Medication dispensing:

• Dispense medications on-site whenever possible and directly observe the first dose to maximize compliance 4