What is the recommended prophylaxis regimen for Chlamydia (sexually transmitted infection) and Gonorrhea (neisseria gonorrhoeae infection)?

Prophylaxis for Chlamydia and Gonorrhea After STD Exposure

The CDC recommends ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days for prophylactic treatment after potential STD exposure. 1

Rationale for Dual Therapy Prophylaxis

• Co-infection rates are extremely high (40-50% of gonorrhea patients also have chlamydia), making presumptive treatment for both organisms essential when empiric prophylaxis is indicated. 1
• This dual approach addresses both organisms with different mechanisms of action, improving efficacy and potentially delaying resistance emergence. 2
• Single-dose azithromycin 1g alone should never be used for gonorrhea prophylaxis, as it has only 93% efficacy and is insufficient as monotherapy. 2, 1

Alternative Prophylactic Regimens

If ceftriaxone is unavailable:

• Use cefixime 400 mg orally single dose PLUS doxycycline 100 mg twice daily for 7 days, but this requires mandatory test-of-cure at 1 week due to inferior efficacy. 1

For severe cephalosporin allergy:

• Azithromycin 2g orally single dose can be used, but causes high gastrointestinal side effects in 35% of patients and requires test-of-cure at 1 week. 1
• Spectinomycin 2g IM is an option, but has poor pharyngeal coverage with only 52% effectiveness and should be avoided if pharyngeal exposure is suspected. 2, 1

Special Population Considerations

In pregnancy:

• Ceftriaxone 500 mg IM single dose is safe and preferred. 1
• Never use doxycycline, quinolones, or tetracyclines in pregnancy. 1, 3
• For chlamydia coverage in pregnancy, substitute azithromycin 1g orally single dose or amoxicillin 500 mg three times daily for 7 days. 1, 3

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea prophylaxis due to widespread resistance. 2, 1
• Never rely on azithromycin 1g alone for gonorrhea coverage due to insufficient 93% efficacy. 2, 1
• Avoid spectinomycin if pharyngeal exposure is suspected, as it has only 52% effectiveness at this site. 2, 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives and is strongly preferred. 2

Partner Management and Follow-Up

• All sexual partners from the preceding 60 days should be evaluated and treated for both N. gonorrhoeae and C. trachomatis. 1, 3
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1
• Routine test-of-cure is not needed for patients treated with recommended regimens (ceftriaxone + doxycycline) unless symptoms persist. 1
• All patients should be retested approximately 3 months after treatment due to high reinfection risk. 1, 3

Important Clinical Context

• The 2021 CDC guidelines increased ceftriaxone dosing to 500mg (from previous 250mg) based on antimicrobial stewardship principles and rising azithromycin resistance. 4
• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone the only reliably effective treatment for pharyngeal sites. 2
• Medications should be dispensed on-site when possible, with directly observed first dose to maximize compliance. 3