What is the recommended antibiotic regimen to cover both gonorrhea and chlamydia?

Recommended Antibiotic Regimen for Gonorrhea and Chlamydia

The recommended treatment is ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, which provides optimal coverage for both gonorrhea and chlamydia in a single-visit regimen. 1, 2

Primary Dual Therapy Regimen

• Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) is the CDC-recommended first-line treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 2, 3
• This regimen achieves a 99.1% cure rate for urogenital and anorectal gonorrhea while simultaneously treating chlamydia with single-dose therapy 1
• Co-infection rates are extremely high (40-50% of gonorrhea patients also have chlamydia), making dual therapy essential even when only one infection is confirmed 1, 2, 4

Rationale for This Specific Combination

• Azithromycin 1 g is preferred over doxycycline due to the convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin 1
• Dual therapy addresses rising antibiotic resistance patterns and potentially delays emergence and spread of cephalosporin resistance 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives 1, 2

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally (single dose) + Azithromycin 1 g orally (single dose) can be used if ceftriaxone is unavailable 1, 2
  • Mandatory test-of-cure at 1 week is required with this regimen due to inferior efficacy compared to ceftriaxone 1, 2
  • Rising cefixime MICs have resulted in declining effectiveness for urogenital gonorrhea 1

Severe Cephalosporin Allergy

• Azithromycin 2 g orally (single dose) is recommended for patients with severe cephalosporin allergy 1, 2
  • This regimen has lower efficacy (only 93%) and high gastrointestinal side effects (35% of patients) 1, 4
  • Mandatory test-of-cure at 1 week is required 1, 2

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates 1, 2, 4
• Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy (only 93% cure rate) 1, 2, 4
• Never use spectinomycin if pharyngeal exposure is suspected, as it has only 52% efficacy for pharyngeal infections 1, 2, 4

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections 1
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 1

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) 2, 4
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 5, 4, 6

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1
• Do not use quinolones for infections in MSM 5, 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, 7, 8, 9, 10
• All patients should be retested approximately 3 months after treatment due to high reinfection risk (most infections result from reinfection, not treatment failure) 1, 2, 7, 8, 9, 10
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 5, 1

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen 1, 2, 4
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 2, 4
• If partners cannot be linked to timely evaluation, consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) 1

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 2
• Report the case to local public health officials within 24 hours 1, 2
• Consult an infectious disease specialist 1, 2
• Recommended salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally or ertapenem 1 g IM for 3 days 1, 2