What are the oral antibiotic treatment options for gonorrhea and chlamydia that do not require injections?

Oral Treatment Options for Gonorrhea and Chlamydia Without Injection

For patients requiring non-injection treatment, use cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose, with mandatory test-of-cure at 1 week due to inferior efficacy compared to injectable ceftriaxone. 1, 2

Primary Oral Regimen

• Cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) is the recommended oral alternative when ceftriaxone injection is unavailable or refused 1, 2, 3
• This regimen requires mandatory follow-up testing at 1 week because cefixime has lower efficacy than ceftriaxone, particularly for pharyngeal infections 1, 2
• The dual therapy addresses both gonorrhea and chlamydia, as co-infection rates reach 40-50% 1, 2

Alternative Oral Regimen for Chlamydia Coverage

• If azithromycin cannot be used, substitute doxycycline 100 mg orally twice daily for 7 days for chlamydia coverage while maintaining cefixime 400 mg for gonorrhea 1, 4, 5
• Doxycycline is contraindicated in pregnancy, nursing women, and children under 8 years 6, 7

Critical Limitations of Oral Therapy

• Cefixime has significantly lower efficacy than ceftriaxone for pharyngeal gonorrhea, which is already the most difficult site to eradicate 1, 2
• Oral cephalosporins were removed from CDC recommendations in 2012 as first-line therapy due to rising minimum inhibitory concentrations (MICs) 1
• Never use quinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite their historical 99.8% cure rates 1, 2, 7

Severe Cephalosporin Allergy Option

• For patients with documented severe cephalosporin allergy: azithromycin 2 g orally as a single dose 1, 2
• This regimen has only 93% efficacy for gonorrhea and causes significant gastrointestinal side effects 1, 2
• Mandatory test-of-cure at 1 week is required 1, 2
• This is the only truly oral-only option, but should be reserved for patients with genuine severe allergies 1

Site-Specific Considerations

• Pharyngeal gonorrhea requires special attention: cefixime has substantially lower efficacy than ceftriaxone for throat infections 1, 2
• If pharyngeal exposure is suspected, strongly counsel patients that oral therapy is suboptimal and injection is preferred 1, 2
• Urogenital and anorectal infections respond better to oral cefixime than pharyngeal infections 1

Special Populations

Pregnancy

• Use cefixime 400 mg orally PLUS azithromycin 1 g orally if injection is refused 6, 2
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 6, 1, 2

Men Who Have Sex With Men (MSM)

• Oral therapy is NOT recommended for MSM due to higher prevalence of resistant strains 1, 2
• If oral therapy must be used, mandatory test-of-cure is essential 1

Mandatory Follow-Up Requirements

• All patients receiving oral cefixime-based therapy require test-of-cure at 1 week 1, 2
• If nucleic acid amplification testing is positive at follow-up, confirm with culture and antimicrobial susceptibility testing 1
• All patients should be retested at 3 months due to high reinfection risk 1, 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately 1, 5

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen 1, 2
• Patients must 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 access timely evaluation 1

Critical Pitfalls to Avoid

• Never use azithromycin 1 g alone for gonorrhea - it has only 93% efficacy and promotes resistance 1, 2, 8
• Never use quinolones - widespread resistance makes them obsolete despite past effectiveness 1, 2, 7, 9
• Never substitute oral therapy for injection in MSM or pharyngeal infections without compelling reason 1, 2
• Do not skip the mandatory test-of-cure at 1 week when using oral cefixime 1, 2

Treatment Failure Management

• If treatment failure occurs with oral therapy, obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 5
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1, 5
• Salvage regimens require injectable therapy: gentamicin 240 mg IM PLUS azithromycin 2 g orally 1