What is the recommended treatment for gonococcal urethritis?

Treatment for Gonococcal Urethritis

For uncomplicated gonococcal urethritis, administer ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 7 days to cover possible chlamydial coinfection. 1

Primary Treatment Regimen

The 2020 CDC update represents the most current guidance and supersedes older recommendations:

• Ceftriaxone 500 mg IM single dose is now the recommended first-line therapy, increased from the previous 250 mg dose 1
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been excluded 1
• This dual therapy approach addresses the high rate of chlamydial coinfection while maintaining antimicrobial stewardship 1

The shift away from routine azithromycin dual therapy reflects increasing azithromycin resistance and concerns about antimicrobial stewardship, while ceftriaxone resistance remains rare 1.

Alternative Regimens

For Patients Unable to Receive Ceftriaxone

• Cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally PLUS mandatory test-of-cure in 1 week 2, 3
  • Note: Cefixime is less effective than ceftriaxone with declining effectiveness and rising MICs 2
  • The oral route may improve compliance but requires follow-up verification 2

For Severe Cephalosporin Allergy

• Azithromycin 2 g orally as a single dose PLUS mandatory test-of-cure in 1 week 2

  • This regimen causes significant gastrointestinal distress 4
  • Resistance concerns make this a last-resort option 5
  • A 2007 study showed 100% cure rates with 2 g azithromycin, but more recent data from 2016 demonstrates increasing treatment failures, particularly with strains having MIC ≥0.5 mg/L 6, 5

• Spectinomycin 2 g IM single dose is another alternative for cephalosporin-allergic patients 4

  • Effective for urogenital infections (96.7% cure rate) but only 52% effective for pharyngeal gonorrhea 4, 7
  • Limited availability in many regions 4

Critical Management Components

Partner Notification and Treatment

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia 4, 2
• If last sexual contact was >60 days before symptom onset, treat the most recent partner 4
• Patients and partners must abstain from sexual intercourse until therapy is completed (7 days after single-dose regimen or after completion of 7-day regimen) and symptoms have resolved 4, 2

Follow-Up Considerations

• Test-of-cure is NOT routinely required for patients treated with recommended ceftriaxone-based regimens 4
• Test-of-cure IS mandatory when using alternative regimens (cefixime or azithromycin monotherapy) due to lower efficacy 2
• Patients with persistent symptoms after treatment should undergo culture with antimicrobial susceptibility testing 4, 1
• Most post-treatment infections represent reinfection rather than treatment failure, indicating need for partner treatment 4

Special Populations

Pregnancy

• Pregnant women should receive ceftriaxone (same dose as non-pregnant patients) 4
• Avoid quinolones and tetracyclines completely in pregnancy 4
• For cephalosporin allergy: spectinomycin 2 g IM single dose 4
• Use erythromycin or amoxicillin for presumptive chlamydial coinfection 4

HIV-Infected Patients

• Use the same treatment regimen as HIV-negative patients 4, 2
• Treatment is particularly vital as cervicitis/urethritis increases HIV shedding and transmission risk 2

Critical Pitfalls to Avoid

• Do not use quinolones (ciprofloxacin, ofloxacin) as first-line therapy despite older guidelines recommending them—resistance is now widespread 4, 8
• Do not rely on cefixime as first-line therapy due to declining effectiveness 2
• Do not use azithromycin 1 g as monotherapy for gonorrhea—it cures only 93% of infections 4
• Do not skip partner treatment—this is the primary cause of apparent treatment failure 4, 1
• Do not use calcium-containing diluents with ceftriaxone due to precipitation risk 9
• Always report suspected treatment failures to CDC through local/state health departments within 24 hours and obtain antimicrobial susceptibility testing 2, 1