What is the recommended treatment regimen for gonorrhea, specifically the injection (intramuscular) therapy?

Gonorrhea Injection Treatment

The recommended intramuscular injection for gonorrhea is ceftriaxone 500 mg IM as a single dose, combined with azithromycin 1 g orally as a single dose. 1, 2, 3

Primary Treatment Regimen

Ceftriaxone 500 mg IM + azithromycin 1 g orally (both single doses) is the first-line treatment for uncomplicated gonorrhea at all anatomic sites including urogenital, anorectal, and pharyngeal infections. 1, 2, 3

Rationale for Dual Therapy

• The dual therapy approach addresses rising antimicrobial resistance patterns and improves treatment efficacy while potentially delaying emergence of cephalosporin resistance 2
• Azithromycin 1 g simultaneously treats presumptive chlamydial coinfection, which occurs in 40-50% of gonorrhea cases 2
• The dose increase from 250 mg to 500 mg reflects evolving resistance patterns and antimicrobial stewardship concerns 1, 3

Administration Details

• Ceftriaxone should be injected deep intramuscularly into a large muscle mass with aspiration to avoid intravascular injection 4
• The azithromycin component is given as a single 1 g oral dose simultaneously with the injection 1, 2
• Do not use diluents containing calcium (such as Ringer's solution) for reconstitution, as precipitation can occur 4

Alternative Injectable Regimens

When Ceftriaxone is Unavailable

If ceftriaxone is not available, use cefixime 400 mg orally PLUS azithromycin 1 g orally, with mandatory test-of-cure at 1 week. 2

For Severe Cephalosporin Allergy

Patients with severe cephalosporin allergy should receive azithromycin 2 g orally as a single dose (not split), with mandatory test-of-cure at 1 week. 5, 1, 2

• Splitting the 2 g dose would reduce peak serum concentrations and tissue penetration, compromising efficacy 5
• This regimen has lower efficacy (93%) and high gastrointestinal side effects 2
• Culture is preferred for test-of-cure as it allows antimicrobial susceptibility testing 5

Alternative Non-Cephalosporin Injectable Options

Gentamicin 240 mg IM PLUS azithromycin 2 g orally achieved 100% cure rate in clinical trials and represents a viable alternative for cephalosporin-allergic patients. 2, 6

• However, gentamicin has poor pharyngeal efficacy (only 20% cure rate) and should be avoided for pharyngeal infections 1, 2
• Spectinomycin 2 g IM has only 52% efficacy for pharyngeal infections and should not be used for oral gonorrhea 1, 2

Site-Specific Considerations

Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone the only reliably effective first-line agent. 1, 2

• Ceftriaxone 500 mg IM has superior efficacy for pharyngeal infections compared to all oral alternatives 1, 2
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 2

Critical Pitfalls to Avoid

Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rate. 1, 2, 3

Never use azithromycin 1 g alone for gonorrhea treatment, as it has only 93% efficacy. 5, 1, 2

Never use spectinomycin or gentamicin for pharyngeal infections due to poor efficacy (52% and 20% respectively). 1, 2

Mandatory Concurrent Actions

Screening and Testing

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1, 2
• Co-test for HIV given that gonorrhea facilitates HIV transmission 2

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 1, 2
• If last sexual contact was >60 days before diagnosis, treat the most recent partner 1
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 2
• Instruct patients to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 2

Follow-Up Requirements

Patients treated with the recommended ceftriaxone 500 mg IM + azithromycin 1 g regimen do not need routine test-of-cure unless symptoms persist. 1, 2

• Consider retesting at 3 months due to high reinfection risk 1, 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 2

Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy. 5, 1, 2

Special Populations

Pregnancy

Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally—the same regimen as non-pregnant patients. 1, 2

• Never use quinolones or tetracyclines in pregnancy 1, 2
• Doxycycline is contraindicated in pregnancy, nursing women, and children under 8 years 2

Men Who Have Sex with Men (MSM)

Only use ceftriaxone for MSM due to higher prevalence of resistant strains—never use quinolones. 1, 2

• Do not use patient-delivered partner therapy for MSM due to high risk of undiagnosed coexisting STDs or HIV 2

Neonates

• Intravenous doses should be given over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 4
• Ceftriaxone is contraindicated in premature neonates and in neonates ≤28 days requiring calcium-containing IV solutions 4

Treatment Failure Management

If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately, report to public health within 24 hours, and consult an infectious disease specialist. 5, 1, 2

Salvage Regimens for Treatment Failure

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