What is the treatment for gonorrhea?

Gonorrhea Treatment

Treat uncomplicated gonorrhea with ceftriaxone 500 mg IM plus azithromycin 1 g orally, both as single doses—this dual therapy is the only acceptable first-line regimen due to rising antimicrobial resistance and high rates of chlamydial co-infection. 1, 2, 3

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the standard of care for all anatomic sites including cervical, urethral, rectal, and pharyngeal infections 1, 2, 3
• The dose has been increased from the older 250 mg recommendation to 500 mg due to evolving resistance patterns and antimicrobial stewardship concerns 2
• This regimen achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1

Why Dual Therapy is Mandatory

• Dual therapy addresses two critical issues: rising cephalosporin resistance (requiring combination therapy with different mechanisms of action) and extremely common chlamydial co-infection occurring in 40-50% of gonorrhea patients 1, 3
• Azithromycin 1 g alone has only 93% efficacy and is insufficient as monotherapy 1
• The azithromycin component provides single-dose chlamydia coverage, eliminating the need for 7-day doxycycline therapy 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) can be used when ceftriaxone is not available 1, 3, 4
• Mandatory test-of-cure at 1 week is required with this regimen due to declining effectiveness of cefixime related to rising MICs 1, 3
• This oral alternative should not be used for pharyngeal infections, as ceftriaxone has superior efficacy for pharyngeal gonorrhea 1

Severe Cephalosporin Allergy

• Azithromycin 2 g orally (single dose) is the option for patients with severe cephalosporin allergy 1, 2
• This regimen has lower efficacy (only 93%) and high gastrointestinal side effects 1, 5
• Mandatory test-of-cure at 1 week is required 1, 2
• Alternative: Gentamicin 240 mg IM plus azithromycin 2 g orally achieved 100% cure rate in clinical trials 1, 6

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite their historical 99.8% cure rates 1, 3, 7
• Never use azithromycin 1 g alone as it has insufficient efficacy (only 93%) 1
• Never use spectinomycin for pharyngeal infections as it has only 52% efficacy at this site 1, 2
• Never use gentamicin for pharyngeal infections as it has only 20% cure rate for pharyngeal gonorrhea 1

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2, 3
• Ceftriaxone is the only reliably effective treatment for pharyngeal infections and is strongly preferred over all oral alternatives 1, 2
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 1

Special Populations

Pregnancy

• Use the standard regimen: ceftriaxone 500 mg IM PLUS azithromycin 1 g orally 1, 2, 3
• Never use quinolones or tetracyclines in pregnancy 1, 3
• If injection is refused, cefixime 400 mg orally plus azithromycin 1 g orally can be used, but doxycycline is contraindicated 1

Men Who Have Sex with Men (MSM)

• Only use ceftriaxone-based regimens due to higher prevalence of resistant strains in this population 1, 2, 3
• Never use quinolones for MSM 1, 3
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 1

Recent Foreign Travel

• Ceftriaxone is the only recommended treatment for patients with history of recent foreign travel due to higher rates of resistant strains, particularly associated with travel to Asia 1, 7

Follow-Up Requirements

• Patients treated with the recommended ceftriaxone 500 mg IM plus azithromycin 1 g regimen do not need routine test-of-cure unless symptoms persist 1, 2, 3
• Consider retesting all patients at 3 months due to high risk of reinfection 1, 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 1, 3

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 1, 2, 3
• If last contact was >60 days before diagnosis, treat the most recent partner 2
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 1
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 2
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1

Treatment Failure Management

• If treatment failure occurs, obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 3
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1, 3
• Recommended salvage regimens include: gentamicin 240 mg IM plus azithromycin 2 g orally (single dose), spectinomycin 2 g IM plus azithromycin 2 g orally, or ertapenem 1 g IM for 3 days 1, 3

Concurrent Testing

• Screen for syphilis with serology at the time of gonorrhea diagnosis 2
• All patients with sexually-transmitted urethritis or cervicitis should have appropriate cultures for gonorrhea and serologic test for syphilis performed at diagnosis 8