Ciprofloxacin for STI Treatment
Ciprofloxacin is NO LONGER recommended as first-line therapy for gonorrhea due to widespread fluoroquinolone resistance, and it should only be used in highly selected heterosexual patients without travel history in areas with documented low resistance rates. 1
Current Status of Ciprofloxacin for Gonorrhea
When Ciprofloxacin Should NOT Be Used
Ciprofloxacin is contraindicated for gonorrhea treatment in the following populations 1:
- Men who have sex with men (MSM) - resistance rates reached 23.9% in this population 1
- Any patient with recent foreign travel or whose sexual partner has traveled abroad 1
- Infections acquired in California or Hawaii - these areas have documented high quinolone-resistant N. gonorrhoeae (QRNG) prevalence 1
- Any area with known elevated QRNG prevalence 1
Limited Acceptable Use
Ciprofloxacin 500 mg orally as a single dose may still be considered only for 1:
- Heterosexual men and women in areas without elevated resistance
- No history of recent travel (patient or partner)
- Uncomplicated urogenital, anorectal, or pharyngeal gonorrhea
- Must be combined with treatment for chlamydia if coinfection not ruled out 1
Critical caveat: Even in these restricted populations, resistance surveillance data from 2004 showed 6.8% overall ciprofloxacin resistance nationally, and this has only worsened over time 1. The guidelines explicitly state that "ciprofloxacin is no longer universally effective against N. gonorrhoeae in the United States" 1.
Efficacy Data (Historical Context)
When used against susceptible strains, ciprofloxacin demonstrated 1:
- 99.8% cure rate for uncomplicated urogenital and anorectal infections 1
- 96% cure rate for pharyngeal infections 1
However, these efficacy rates are only applicable to susceptible isolates, which are increasingly rare 1.
Other STIs and Ciprofloxacin
NOT Effective Against:
- Chlamydia trachomatis - ciprofloxacin has no reliable activity 2
- Treponema pallidum (syphilis) - no quinolone inhibits this organism 3
- Ureaplasma urealyticum - lacks reliable in vitro activity 3
Limited or Unproven Role:
- Pelvic inflammatory disease - cannot be recommended as single-agent therapy 3
Potentially Effective (but not first-line):
- Haemophilus ducreyi (chancroid) - fluoroquinolones can be effective 3
Practical Clinical Algorithm
Step 1: Obtain detailed sexual history 1:
- Sexual orientation (MSM vs. heterosexual)
- Recent travel history (patient and partners)
- Geographic location of infection acquisition
Step 2: If ANY of the following apply, DO NOT use ciprofloxacin 1:
- MSM
- Recent foreign travel
- California or Hawaii residence/exposure
- Known high-resistance area
Step 3: If treating gonorrhea in 2025, use ceftriaxone 125 mg IM or cefixime 400 mg orally instead 1, 4
Step 4: Always treat presumptively for chlamydia unless ruled out by NAAT 1
Critical Pitfalls to Avoid
- Do not assume ciprofloxacin is still appropriate based on older training or guidelines - resistance has fundamentally changed treatment paradigms 1
- Do not use ciprofloxacin for empiric gonorrhea treatment without detailed risk assessment 1
- Do not rely on ciprofloxacin for chlamydia coverage - it is ineffective and dual therapy is required 2
- Do not use for treatment failures - culture and susceptibility testing is mandatory 1
FDA-Approved Indication
The FDA label lists "uncomplicated cervical and urethral gonorrhea due to Neisseria gonorrhoeae" as an approved indication 5, but this approval predates widespread resistance and does not reflect current clinical reality or guideline recommendations 1.