What is the recommended treatment for gonorrhea in a pregnant patient?

Treatment of Gonorrhea in Pregnancy

Pregnant women with gonorrhea should be treated with ceftriaxone 250-500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, avoiding quinolones and tetracyclines entirely. 1, 2

Primary Recommended Regimen

• Ceftriaxone 250-500 mg IM single dose PLUS azithromycin 1 g orally single dose is the treatment of choice for pregnant women with gonorrhea. 1, 2, 3
• The dual therapy approach addresses both gonorrhea and presumptive chlamydial coinfection, which occurs in 40-50% of gonorrhea cases. 1, 4
• Both medications should be administered on the same day, preferably simultaneously and under direct observation. 2
• This regimen is safe and effective across all trimesters of pregnancy with no increased risk of congenital malformations. 5

Critical Contraindications in Pregnancy

• Never use quinolones (ciprofloxacin, ofloxacin, levofloxacin) in pregnant women - these are absolutely contraindicated despite their historical effectiveness. 6, 1, 4, 7
• Never use tetracyclines (doxycycline) in pregnant women - these are contraindicated throughout pregnancy. 6, 1, 4, 7
• The standard non-pregnancy regimen of ceftriaxone plus doxycycline must be modified to ceftriaxone plus azithromycin. 3

Alternative Regimen for Cephalosporin Allergy

• If the patient cannot tolerate cephalosporins, administer spectinomycin 2 g IM as a single dose PLUS azithromycin 1 g orally. 6
• Critical limitation: Spectinomycin has only 52% efficacy against pharyngeal gonorrhea, so if pharyngeal infection is suspected or confirmed, this regimen is inadequate. 6, 8, 1
• For pharyngeal infections in cephalosporin-allergic pregnant patients, consultation with an infectious disease specialist is essential. 1

Site-Specific Treatment Considerations

• The recommended regimen effectively treats gonorrhea at cervical, urethral, rectal, and pharyngeal sites. 1
• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone the most reliable option. 8, 1
• Ceftriaxone demonstrates 95-99% efficacy across all anatomic sites in pregnant women. 5, 1

Chlamydia Coverage in Pregnancy

• Azithromycin 1 g orally single dose is the preferred agent for presumptive chlamydial treatment in pregnancy. 6, 4
• Alternative option: Amoxicillin 500 mg orally three times daily for 7 days can be used for chlamydia coverage if azithromycin is not tolerated. 8, 4
• Erythromycin base 500 mg orally four times daily for 7 days is another alternative, though compliance is more challenging. 6

Follow-Up Requirements

• Test-of-cure is NOT routinely needed for pregnant women treated with the recommended ceftriaxone plus azithromycin regimen. 2, 4
• Retest in the third trimester - all pregnant women with antenatal gonococcal infection should be retested unless recently treated. 2
• If symptoms persist after treatment, obtain culture for N. gonorrhoeae with antimicrobial susceptibility testing. 6, 1
• Persistent infections after recommended therapy typically represent reinfection rather than treatment failure. 6

Partner Management

• All sexual partners from the preceding 60 days before symptom onset or diagnosis must be evaluated and treated for both gonorrhea and chlamydia. 6, 8, 1, 4
• Partners should receive the same dual therapy regimen (ceftriaxone plus azithromycin). 1
• The patient must avoid sexual intercourse until both she and her partner(s) complete therapy and are asymptomatic. 6, 8, 4
• Expedited partner therapy (providing medication directly to partners) may be considered if partners cannot access timely evaluation. 1

Common Pitfalls to Avoid

• Never use azithromycin 1 g alone for gonorrhea treatment - it has only 93% efficacy and is insufficient as monotherapy. 8, 1, 4
• Never substitute oral cephalosporins (cefixime) as first-line therapy in pregnancy - intramuscular ceftriaxone is strongly preferred for reliability and compliance. 1
• Do not use amoxicillin plus probenecid - this regimen has only 89% efficacy and is no longer recommended. 5
• Avoid spectinomycin if pharyngeal infection is present or suspected due to poor efficacy at this site. 6, 8, 1

Monitoring for Treatment Failure

• If treatment failure is suspected, immediately obtain specimens for culture and antimicrobial susceptibility testing. 1
• Report suspected treatment failures to local public health officials within 24 hours. 1
• Consult an infectious disease specialist for management of treatment failures. 1