What is the recommended treatment for gonorrhea in a patient with a penicillin (pcn) allergy?

Gonorrhea Treatment in Penicillin-Allergic Patients

For patients with penicillin allergy, use ceftriaxone 500 mg intramuscularly as a single dose plus doxycycline 100 mg orally twice daily for 7 days to cover presumptive chlamydial coinfection. 1, 2

Why Ceftriaxone is Safe Despite Penicillin Allergy

• True cross-reactivity between penicillins and third-generation cephalosporins is rare (1-3%), making ceftriaxone safe for most penicillin-allergic patients. 1
• Ceftriaxone is a cephalosporin, not a penicillin, and the structural differences make clinically significant cross-reactivity uncommon. 1
• The 2021 CDC STI Treatment Guidelines updated the ceftriaxone dose to 500 mg (increased from 250 mg) based on pharmacokinetic/pharmacodynamic data and antimicrobial stewardship principles. 2

Regimen for Severe Beta-Lactam Allergy

If the patient has documented severe cephalosporin allergy or anaphylaxis to any beta-lactam:

• Use azithromycin 2 g orally as a single dose. 1
• Mandatory test-of-cure is required 1 week after treatment using culture (preferred over NAAT) because culture allows antimicrobial susceptibility testing. 1
• Do not use azithromycin 1 g as monotherapy—it has insufficient efficacy and promotes resistance. 1, 3

Alternative: Spectinomycin (When Available)

• Spectinomycin 2 g intramuscularly as a single dose achieves 98.2% cure for uncomplicated urogenital and anorectal gonorrhea. 1
• Critical limitation: Spectinomycin is only 52% effective against pharyngeal gonorrhea. 1, 3
• If spectinomycin is used and pharyngeal infection is suspected, obtain pharyngeal culture 3-5 days post-treatment to verify eradication. 1, 3

Quinolones: Not Recommended Without Susceptibility Testing

• Do not use quinolones (ciprofloxacin 500 mg or levofloxacin 250 mg) without documented antimicrobial susceptibility testing due to widespread resistance. 1, 3
• Quinolone-resistant N. gonorrhoeae is particularly common in men who have sex with men, patients with recent foreign travel, and infections acquired in California or Hawaii. 3

Always Treat for Chlamydia Coinfection

• Add doxycycline 100 mg orally twice daily for 7 days unless chlamydial coinfection has been definitively ruled out. 1, 4, 2
• Coinfection with C. trachomatis is common, and presumptive treatment is standard practice. 5
• Alternative for chlamydia coverage: azithromycin 1 g orally as a single dose (if not already used for gonorrhea treatment). 1

Site-Specific Considerations

• Pharyngeal gonorrhea is more difficult to eradicate than urogenital infections—ceftriaxone remains the most effective option. 1, 3
• For pharyngeal infections, avoid spectinomycin due to its 52% failure rate at this site. 1, 3
• Ceftriaxone 500 mg achieves >90% cure rates for pharyngeal, urogenital, and anorectal infections. 5, 2

Essential Management Steps

• Evaluate and treat all sex partners from the preceding 60 days. 1, 3
• Patients must avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1, 3
• Consider retesting at 3 months due to high reinfection rates. 3

Special Population: Pregnancy

• Pregnant women with penicillin allergy should receive ceftriaxone 500 mg intramuscularly, as the cross-reactivity risk is acceptable. 1
• If cephalosporin is absolutely contraindicated, spectinomycin 2 g intramuscularly is an alternative. 1
• Never use doxycycline, quinolones, or tetracyclines in pregnancy. 1

Common Pitfalls to Avoid

• Do not assume penicillin allergy automatically precludes cephalosporin use—most patients can safely receive ceftriaxone. 1
• Do not use oral-only regimens for pharyngeal gonorrhea—parenteral ceftriaxone achieves superior tissue levels. 3
• Do not skip test-of-cure when using azithromycin 2 g monotherapy for severe beta-lactam allergy. 1
• Do not use quinolones empirically without susceptibility testing—resistance rates make this approach unacceptable. 1, 3, 2