What is the recommended treatment for gonorrhea?

Gonorrhea Treatment

Primary Recommendation

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded). 1, 2

Rationale for Current Regimen

• Ceftriaxone 500 mg IM is the cornerstone of gonorrhea treatment, achieving a 99.1% cure rate for uncomplicated urogenital and anorectal infections 1
• The dose was increased from 250 mg to 500 mg in 2020 CDC guidelines to maintain efficacy against evolving resistance patterns 2
• Dual therapy addresses two critical issues: treating likely chlamydial co-infection (present in 40-50% of gonorrhea cases) and potentially delaying emergence of cephalosporin resistance 1
• Azithromycin 1 g is preferred over doxycycline due to single-dose convenience and better compliance, though doxycycline is acceptable if chlamydial infection has not been excluded 1, 2

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives 1
• Ceftriaxone achieves 99.1% cure rates across cervical, urethral, rectal, and pharyngeal sites with single administration 1

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Use cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 1, 3
• Critical caveat: Cefixime is less effective than ceftriaxone, particularly for pharyngeal infections 4
• Mandatory test-of-cure at 1 week is required with this regimen 1
• Oral cephalosporins are no longer first-line due to declining susceptibility 5

For severe cephalosporin allergy:

• Azithromycin 2 g orally single dose with mandatory test-of-cure at 1 week 1
• This regimen has lower efficacy (93% vs 99%) and high gastrointestinal side effects 1, 6
• Gentamicin 240 mg IM PLUS azithromycin 2 g orally achieved 100% cure rate in clinical trials but has poor pharyngeal efficacy (only 20% in some studies) 1, 7, 8

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite historical 99.8% cure rates 1, 9
• Never use azithromycin 1 g alone for gonorrhea treatment—efficacy is only 93% 1
• Never substitute tablets/capsules for suspension in treating otitis media due to different pharmacokinetics 3
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for this site 1

Special Populations

Pregnant women:

• Use ceftriaxone (preferred cephalosporin) PLUS azithromycin 1 g orally 1, 4
• Never use quinolones or tetracyclines in pregnancy 1

Men who have sex with men (MSM):

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1, 4
• Do not use quinolones in this population 4
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 1

Patients with recent foreign travel:

• Ceftriaxone is the only recommended treatment due to higher likelihood of resistant strains 1

Follow-Up and Test-of-Cure Requirements

• Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist 1
• Mandatory test-of-cure at 1 week is required for:
  • Patients receiving cefixime-based regimens 1
  • Patients receiving azithromycin monotherapy 1
  • Patients with severe cephalosporin allergy using alternative regimens 1
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 1, 4
• Consider retesting all patients at 3 months due to high reinfection rates 1

Treatment Failure Management

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 4
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1
• Recommended salvage regimens include:
  • Gentamicin 240 mg IM PLUS azithromycin 2 g orally 1
  • Ertapenem 1 g IM for 3 days 1
• Most ceftriaxone treatment failures involve pharyngeal sites, not urogenital 1

Partner Management

• Evaluate and treat all sex partners from the preceding 60 days 1, 4
• If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner 4
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 1
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1, 4

Concurrent Testing Requirements

• Screen for syphilis with serology at the time of gonorrhea diagnosis 4
• All patients with sexually transmitted urethritis or cervicitis should have appropriate cultures for gonorrhea and testing for other STDs 10
• Test for HIV and other sexually transmitted infections 9