What is the recommended treatment guideline for gonorrhea?

Gonorrhea Treatment Guidelines

Primary Recommended Treatment

The CDC recommends ceftriaxone 500 mg intramuscularly as a single dose for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, with concurrent doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1

This represents an update from the previous 250 mg dose, reflecting the need for higher dosing to maintain efficacy against evolving resistance patterns 1. The shift away from routine azithromycin combination therapy addresses antimicrobial stewardship concerns and rising azithromycin resistance 1.

Alternative Regimens When Ceftriaxone Is Unavailable

• Cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose is the preferred alternative when intramuscular ceftriaxone cannot be administered 2, 3
• This regimen is significantly less effective than ceftriaxone, particularly for pharyngeal infections, and requires mandatory test-of-cure at 1 week 2, 4
• Cefixime achieves lower cure rates and should not be substituted for ceftriaxone in routine practice 5

Severe Cephalosporin Allergy Options

• Azithromycin 2 g orally as a single dose is recommended for patients with documented severe cephalosporin allergy 2, 4
• This regimen has lower efficacy (93% cure rate) and causes significant gastrointestinal side effects 2, 6
• Mandatory test-of-cure at 1 week is required 2
• Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally achieved 100% cure rates in clinical trials and represents an excellent alternative for cephalosporin-allergic patients 2, 7

Critical Site-Specific Considerations

Pharyngeal Gonorrhea

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal infections 2
• Ceftriaxone 500 mg intramuscularly is the only reliably effective treatment for pharyngeal gonorrhea 2
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 2
• Gentamicin also demonstrates poor pharyngeal efficacy (20% cure rate) 2
• Most ceftriaxone treatment failures occur at pharyngeal sites, not urogenital sites 2

Urogenital and Anorectal Infections

• Ceftriaxone achieves 99.1% cure rates for uncomplicated urogenital and anorectal gonorrhea 2
• Both gentamicin/azithromycin and gemifloxacin/azithromycin demonstrated 100% and 99.5% cure rates respectively for urogenital infections 7

Special Populations

Pregnant Women

• Use ceftriaxone 500 mg intramuscularly PLUS azithromycin 1 g orally as a single dose 2
• Ceftriaxone is the preferred cephalosporin in pregnancy 2, 4
• Never use quinolones or tetracyclines in pregnancy 2, 4
• If injection is refused, cefixime 400 mg orally PLUS azithromycin 1 g orally may be used, but this is suboptimal 2

Men Who Have Sex With Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains 2, 4
• Never use quinolones in MSM populations 2, 4
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 2

Pediatric Patients (≥6 months)

• Recommended dose is 8 mg/kg/day of cefixime suspension, administered as a single daily dose or divided into 4 mg/kg every 12 hours 3
• Maximum daily dose should not exceed 400 mg 3

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately 2, 4
• Report the case to local public health officials within 24 hours 2
• Consult an infectious disease specialist 2
• Recommended salvage regimens include:
  • Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally (single dose) 2
  • Ertapenem 1 g intramuscularly for 3 days 2
  • Spectinomycin 2 g intramuscularly PLUS azithromycin 2 g orally (where available) 2

Partner Management

• Evaluate and treat all sex partners from the preceding 60 days 2, 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 2
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 2
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 2

Follow-Up and Testing Requirements

• Patients treated with recommended ceftriaxone regimens do not need routine test-of-cure unless symptoms persist 2
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 2, 4
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 2
• If nucleic acid amplification testing is positive at follow-up, confirm with culture, and all positive cultures should undergo phenotypic antimicrobial susceptibility testing 2
• Screen for syphilis with serology at the time of gonorrhea diagnosis 4

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance 5, 2, 1
• Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy (only 93% cure rate) 2
• Never substitute tablets or capsules for suspension in the treatment of otitis media in pediatric patients, as suspension results in higher peak blood levels 3
• Do not use oral cephalosporins as first-line therapy when intramuscular ceftriaxone is available 5
• Cefixime has superior efficacy for pharyngeal infections compared to oral alternatives and is strongly preferred over other oral options 2

Concurrent Chlamydia Coverage

• Co-infection is extremely common, with 40-50% of patients with gonorrhea also having chlamydia 2
• If chlamydial infection has not been excluded, concurrent treatment with doxycycline 100 mg orally twice daily for 7 days is recommended 1
• Azithromycin 1 g orally provides single-dose chlamydia coverage, eliminating the need for 7-day doxycycline in compliant patients 2
• The shift to doxycycline reflects antimicrobial stewardship concerns about routine azithromycin use 1