What is the next step in treatment for a patient with uncomplicated gonorrhea who has been on cefixime (Cefixime) 400 mg orally once daily for 3 days?

Immediate Treatment Correction Required

This patient has been incorrectly treated with cefixime for 3 days when gonorrhea requires single-dose therapy, not multi-day dosing—you must immediately stop the current regimen and administer the correct single-dose treatment: ceftriaxone 250 mg IM plus azithromycin 1 g orally. 1, 2

Critical Error in Current Management

• Cefixime is administered as a single 400 mg oral dose, not as a multi-day course 1
• The patient receiving cefixime for 3 consecutive days represents a fundamental misunderstanding of gonorrhea treatment protocols 2, 3
• This incorrect dosing schedule may contribute to treatment failure and antimicrobial resistance 1

Correct Next Steps

Immediate Action Required

• Discontinue the current incorrect cefixime regimen immediately 2
• Administer ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose 1, 2
• This is the CDC-recommended first-line treatment for uncomplicated gonorrhea 1, 2

Test-of-Cure Requirement

• Schedule a test-of-cure in 1 week because the patient received an alternative (and incorrectly administered) regimen 1
• Test-of-cure should ideally be performed with culture, or with NAAT if culture is unavailable 1
• If culture is positive at test-of-cure, perform phenotypic antimicrobial susceptibility testing 1

If Treatment Failure Occurs

• Treat with ceftriaxone 250 mg IM plus azithromycin 2 g orally as single doses 1
• Obtain infectious disease consultation 1
• Report the case to CDC through local/state health department within 24 hours 1
• Perform culture with antimicrobial susceptibility testing 1

Why Ceftriaxone is Preferred Over Cefixime

• Ceftriaxone 125-250 mg IM achieves 98.9-99.1% cure rates compared to cefixime's 97.4% 1, 3, 4
• Ceftriaxone provides sustained, high bactericidal blood levels that cefixime cannot match 1, 3
• Cefixime is only recommended when ceftriaxone is not readily available 1
• When cefixime is used as an alternative, it must be given as a single 400 mg dose, not multiple days 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days with the recommended regimen (ceftriaxone 250 mg IM plus azithromycin 1 g orally) 1
• Consider expedited partner therapy if partners cannot be linked to timely evaluation 1

Common Pitfalls to Avoid

• Never treat gonorrhea with multi-day courses of cefixime—this is not evidence-based and risks resistance 1, 2, 3
• Always co-treat for chlamydia with azithromycin or doxycycline, as at least 50% of gonorrhea patients have concurrent chlamydial infection 4, 5
• Do not use fluoroquinolones due to widespread resistance 1, 2
• Failing to perform test-of-cure after alternative regimens can miss treatment failures 1