What is the recommended treatment for gonorrhea?

Gonorrhea Treatment

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus azithromycin 1 g orally as a single dose for dual therapy coverage of both gonorrhea and presumptive chlamydial coinfection. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the optimal first-line therapy for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 2
• This dual therapy achieves a 99.1% cure rate for urogenital and anorectal gonorrhea 1
• The combination addresses the critical issue of coinfection, as 40-50% of gonorrhea patients also have chlamydia 1, 2

Rationale for Dual Therapy

• Dual therapy with two antimicrobials having different mechanisms of action improves treatment efficacy and potentially delays emergence of cephalosporin resistance 1
• Rising antibiotic resistance patterns necessitate combination therapy rather than monotherapy 1
• The azithromycin component provides single-dose chlamydia coverage, eliminating the need for 7-day doxycycline in compliant patients 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) can be used if ceftriaxone is unavailable 1, 3, 4
• Critical caveat: This regimen is less effective than ceftriaxone, particularly for pharyngeal infections, and requires mandatory test-of-cure at 1 week 1, 3
• Rising cefixime MICs have resulted in declining effectiveness for urogenital gonorrhea treatment 1

Severe Cephalosporin Allergy Options

• Azithromycin 2 g orally (single dose) is recommended for patients with severe cephalosporin allergy 1, 3, 5
• This regimen has lower efficacy (only 93% cure rate) and high gastrointestinal side effects 1, 6
• Mandatory test-of-cure at 1 week is required 1, 3
• Gentamicin 240 mg IM (single dose) PLUS azithromycin 2 g orally (single dose) is an alternative with 100% cure rate in clinical trials 1, 7

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all alternative treatments 1, 2
• Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected 1, 2
• Gentamicin also has poor pharyngeal efficacy (only 20% cure rate) 1
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 1

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rate 1, 2
• Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy at only 93% cure rate 1, 2
• Never substitute tablets/capsules for suspension in treating otitis media, as suspension results in higher peak blood levels 4

Special Populations

Pregnancy

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the recommended treatment 1, 2
• Never use quinolones or tetracyclines in pregnancy 1, 2

Men Who Have Sex With Men (MSM)

• Use only ceftriaxone-based regimens due to higher prevalence of resistant strains 1, 3
• Quinolones are contraindicated in this population 1, 3
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 1

Recent Foreign Travel

• Ceftriaxone is the only recommended treatment for patients with history of recent foreign travel due to higher likelihood of resistant strains 1

Follow-Up Requirements

• Patients treated with the recommended ceftriaxone plus azithromycin regimen do NOT need routine test-of-cure unless symptoms persist 1, 2
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime-based regimens or azithromycin monotherapy 1, 3
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 1, 2
• If symptoms persist after treatment, evaluate by culture for N. gonorrhoeae with antimicrobial susceptibility testing 1
• If nucleic acid amplification testing is positive at follow-up, confirm with culture, and all positive cultures should undergo phenotypic antimicrobial susceptibility testing 1

Treatment Failure Management

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1
• Recommended salvage regimens include:
  • Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1
  • Ertapenem 1 g IM for 3 days 1
  • Spectinomycin 2 g IM PLUS azithromycin 2 g orally 1

Partner Management

• All sexual partners from the preceding 60 days should be evaluated and treated with the same dual therapy regimen 1, 3, 2
• If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner 3
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 2
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1

Concurrent Testing Requirements

• Screen for syphilis with serology at the time of gonorrhea diagnosis 3
• All patients with sexually-transmitted urethritis or cervicitis should have appropriate cultures for gonorrhea and serologic test for syphilis performed at diagnosis 5