What is the recommended treatment for gonorrhea?

Recommended Treatment for Gonorrhea

The first-line treatment for uncomplicated gonorrhea is ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose. 1, 2

Primary Treatment Regimen

• Ceftriaxone 250 mg IM (single dose) + azithromycin 1 g orally (single dose) is the most reliably effective treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. 3, 1
• This dual therapy achieves a 99.1% cure rate for uncomplicated urogenital and anorectal infections. 1
• The combination addresses two critical issues: rising antimicrobial resistance in Neisseria gonorrhoeae and the extremely common co-infection with Chlamydia trachomatis (occurring in 40-50% of gonorrhea cases). 1, 2

Rationale for Dual Therapy

• Dual therapy with two antimicrobials having different mechanisms of action improves treatment efficacy and delays emergence of cephalosporin resistance. 1, 2
• Azithromycin is preferred over doxycycline due to single-dose convenience, better compliance, and substantially lower prevalence of gonococcal resistance to azithromycin compared to tetracyclines. 1
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy and is insufficient as monotherapy. 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally (single dose) + azithromycin 1 g orally (single dose) can be used if ceftriaxone is unavailable. 3, 1, 4
• Mandatory test-of-cure at 1 week is required with this regimen due to declining cefixime susceptibility and treatment failures reported in Europe. 3, 1
• Cefixime is no longer recommended as first-line therapy because minimum inhibitory concentrations have been rising, suggesting waning effectiveness. 3

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
• This regimen has lower efficacy (93%) and higher gastrointestinal side effects. 1
• Alternative: Gentamicin 240 mg IM (single dose) + azithromycin 2 g orally (single dose) achieved 100% cure rates in clinical trials. 1

Critical Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 1, 2
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives and is strongly preferred. 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for this site. 1
• Gentamicin also has poor pharyngeal efficacy (only 20% cure rate). 1

Antimicrobial Resistance: What NOT to Use

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance. 3, 1, 2
• Fluoroquinolones were removed from CDC recommendations in 2007 after resistance became prevalent, particularly among men who have sex with men. 3
• Oral cephalosporins (cefixime) are no longer first-line therapy due to declining susceptibility. 3

Special Populations

Pregnant Women

• Use the standard regimen: ceftriaxone 250 mg IM + azithromycin 1 g orally. 1, 2
• Never use quinolones or tetracyclines (doxycycline) in pregnancy. 1, 2
• Ceftriaxone is the preferred cephalosporin in pregnancy. 1

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains in this population. 1, 2
• Do not use quinolones for infections in MSM. 1
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV. 1

Patients with Recent Foreign Travel

• Ceftriaxone is the only recommended treatment for patients with history of recent foreign travel, particularly to Asia where ceftriaxone-resistant strains are spreading. 1

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia. 1, 2
• Partners should receive the same dual therapy regimen. 1
• Patients must avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic. 1
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg + azithromycin 1 g) if partners cannot be linked to timely evaluation. 1

Follow-Up and Test-of-Cure

• Patients treated with the recommended ceftriaxone + azithromycin regimen do NOT need routine test-of-cure unless symptoms persist. 1, 2
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy. 1
• Retest all patients 3 months after treatment due to high risk of reinfection (not treatment failure). 1, 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing. 1, 2

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately. 1, 2
• Report the case to local public health officials within 24 hours. 1
• Consult an infectious disease specialist. 1, 2
• Recommended salvage regimens include:
  • Gentamicin 240 mg IM + azithromycin 2 g orally (single dose) 1
  • Spectinomycin 2 g IM + azithromycin 2 g orally 1
  • Ertapenem 1 g IM for 3 days 1
• Most ceftriaxone treatment failures involve pharyngeal infections, not urogenital sites. 1

Common Pitfalls to Avoid

• Do not substitute oral cefixime for ceftriaxone in pharyngeal infections—ceftriaxone is far superior. 1
• Do not use azithromycin 1 g as monotherapy—it is insufficient with only 93% efficacy. 1
• Do not skip the azithromycin component even if chlamydia testing is negative—dual therapy is essential for resistance prevention. 3
• Do not use fluoroquinolones under any circumstances for gonorrhea treatment in the current era. 3, 1
• For otitis media in children, use the suspension formulation, not tablets or capsules, as the suspension achieves higher peak blood levels. 4