What is the recommended treatment for gonorrhoea?

Treatment for Gonorrhoea

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, with doxycycline 100 mg orally twice daily for 7 days added only if chlamydia coinfection has not been excluded. 1, 2, 3

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the foundation of gonorrhea treatment, effective for cervical, urethral, rectal, and pharyngeal infections 1, 2, 3
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydia coinfection has not been ruled out 3
• This represents an update from older dual therapy recommendations (ceftriaxone 250 mg + azithromycin 1 g) due to rising azithromycin resistance, with nearly 5% of isolates showing elevated azithromycin MICs by 2018 3, 4
• Ceftriaxone MICs have remained stable in the United States with <0.1% exhibiting alert values, making it the most reliable single agent 3, 5

Alternative Regimens When Ceftriaxone Unavailable

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose if ceftriaxone cannot be administered 1, 2, 6
• Mandatory test-of-cure at 1 week is required with this regimen due to declining cefixime effectiveness related to rising MICs 1, 2
• This oral regimen has inferior efficacy compared to ceftriaxone, particularly for pharyngeal infections 1, 7

Severe Cephalosporin Allergy Options

• Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally single dose achieved 100% cure rate in clinical trials 1, 8
• Critical limitation: Gentamicin has poor pharyngeal efficacy (only 20% cure rate), making it unsuitable for pharyngeal gonorrhea 1
• Azithromycin 2 g orally alone is an option but has lower efficacy (93%) and high gastrointestinal side effects 1, 2
• No recommended alternatives exist for pharyngeal gonorrhea in cephalosporin-allergic patients 3

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2, 7
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all alternatives 1, 7
• Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used for suspected pharyngeal exposure 1, 7

Special Populations

Pregnancy

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose 1, 2, 7
• Never use quinolones, tetracyclines, or doxycycline in pregnancy 1, 2, 7

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1, 2
• Never use quinolones in this population 1, 2

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite historical 99.8% cure rates 1, 2, 7
• Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy (only 93% cure rate) 1, 7
• Never substitute tablets/capsules for suspension when treating otitis media, as suspension achieves higher peak blood levels 6

Follow-Up Requirements

• No routine test-of-cure needed for patients treated with recommended ceftriaxone regimen unless symptoms persist 1, 2, 7
• Mandatory test-of-cure at 1 week required for patients receiving cefixime or azithromycin monotherapy 1, 2
• Retest all patients at 3 months due to high reinfection risk 2, 7
• If symptoms persist, obtain culture with antimicrobial susceptibility testing 1, 2

Treatment Failure Management

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 2
• Report to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1, 2
• Salvage regimens include: gentamicin 240 mg IM PLUS azithromycin 2 g orally, spectinomycin 2 g IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days 1, 2
• Most treatment failures occur with pharyngeal infections, not urogenital sites 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 1, 2, 7
• Partners should receive the same dual therapy regimen 1
• Patients must avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 7
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1

Coinfection Considerations

• 40-50% of gonorrhea patients have concurrent chlamydia infection, making empiric chlamydia coverage essential when testing is unavailable 2, 7
• All patients with gonorrhea should have serologic testing for syphilis performed at diagnosis 9