What is the recommended treatment regimen for gonorrhea?

Gonorrhea Treatment

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus azithromycin 1 g orally as a single dose for dual therapy coverage. 1

Primary Treatment Regimen

Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) is the optimal first-line therapy for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx. 1, 2

• This dual therapy achieves a 99.1% cure rate for urogenital and anorectal gonorrhea 1
• Azithromycin provides concurrent coverage for possible chlamydial co-infection (present in 40-50% of gonorrhea cases) 1
• The combination addresses rising antibiotic resistance patterns and may delay emergence of cephalosporin resistance 1

Dosing Specifications

• Ceftriaxone: 500 mg intramuscularly as a single injection 1, 3
• Azithromycin: 1 g orally as a single dose 1
• Administer without regard to food 4

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available, use cefixime 400 mg orally plus azithromycin 1 g orally as a single dose, with mandatory test-of-cure at 1 week. 1, 5

• Cefixime is less effective than ceftriaxone, particularly for pharyngeal infections 5
• Rising cefixime MICs have resulted in declining effectiveness 1
• Test-of-cure is mandatory due to inferior efficacy 1, 5

Severe Cephalosporin Allergy

For patients with severe cephalosporin allergy, use azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week. 1, 5

• This regimen has lower efficacy (only 93% cure rate) 1
• High gastrointestinal side effects occur frequently 1, 6
• Alternative: Gentamicin 240 mg IM plus azithromycin 2 g orally (100% cure rate in trials) 1

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 alternatives 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 1
• Gentamicin has only 20% cure rate for pharyngeal infections 1

Special Populations

Pregnant Women

Use ceftriaxone 500 mg IM plus azithromycin 1 g orally. 1, 5

• Ceftriaxone is the preferred cephalosporin in pregnancy 1
• Never use quinolones or tetracyclines in pregnancy 1, 5
• Doxycycline is contraindicated 1

Men Who Have Sex with Men (MSM)

Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains. 1, 5

• Do not use quinolones in MSM 1, 5
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Neonates

Ceftriaxone is contraindicated in premature neonates and in neonates ≤28 days requiring calcium-containing IV solutions. 3

• If used, administer intravenously over 60 minutes to reduce risk of bilirubin encephalopathy 3
• Do not use in hyperbilirubinemic neonates 3

Critical Pitfalls to Avoid

Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance. 1, 7

Never use azithromycin 1 g alone for gonorrhea—it has insufficient efficacy (only 93% cure rate). 1

Never use ceftriaxone with calcium-containing diluents or IV solutions—precipitation can occur. 3

Partner Management

Evaluate and treat all sexual partners from the preceding 60 days. 1, 5

• If last sexual contact was >60 days before diagnosis, treat the most recent partner 5
• Partners should receive the same dual therapy regimen 1
• Patients should avoid sexual intercourse until therapy is completed and both partners are asymptomatic 1
• Consider expedited partner therapy with oral combination (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1, 5

Follow-Up 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, 5
• Patients receiving azithromycin monotherapy 1
• Patients with severe cephalosporin allergy receiving alternative regimens 1, 5

If symptoms persist after treatment:

• Obtain culture with antimicrobial susceptibility testing immediately 1, 5
• Report suspected treatment failure to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1

Consider retesting all patients 3 months after treatment due to high risk of reinfection. 1

Treatment Failure Management

For suspected ceftriaxone treatment failure, recommended salvage regimens include: 1

• Gentamicin 240 mg IM plus azithromycin 2 g orally (single dose)
• Ertapenem 1 g IM for 3 days
• Spectinomycin 2 g IM plus azithromycin 2 g orally (avoid for pharyngeal infections)

Concurrent Testing

Screen for syphilis with serology at the time of gonorrhea diagnosis. 5

Screen for chlamydial co-infection, as it is present in 40-50% of gonorrhea cases. 1