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, which provides dual coverage for gonorrhea and presumptive chlamydial coinfection. 1, 2, 3
Primary Treatment Regimen
Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) is the first-line therapy for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx. 1, 2, 3
This dual therapy achieves a 99.1% cure rate for urogenital and anorectal gonorrhea and addresses the 40-50% coinfection rate with chlamydia. 1, 2
The dose increase from 250 mg to 500 mg ceftriaxone reflects evolving antimicrobial stewardship concerns and resistance patterns. 3
Critical Rationale for Dual Therapy
Dual therapy with different mechanisms of action improves treatment efficacy and potentially delays emergence of cephalosporin resistance. 1
Azithromycin provides single-dose chlamydial coverage, eliminating the need for 7-day doxycycline in compliant patients. 1
If chlamydial infection has been excluded by testing, doxycycline 100 mg orally twice daily for 7 days may be substituted for azithromycin. 3
Alternative Regimens (When Ceftriaxone Unavailable)
Cefixime 400 mg orally (single dose) + Azithromycin 1 g orally (single dose) is the alternative regimen, but requires mandatory test-of-cure at 1 week due to inferior efficacy. 1, 2, 4
For severe cephalosporin allergy: Azithromycin 2 g orally as a single dose with mandatory test-of-cure at 1 week, though this has lower efficacy (93%) and high gastrointestinal side effects. 1, 5
Gentamicin 240 mg IM + Azithromycin 2 g orally (single dose) achieved 100% cure rates in clinical trials and represents an emerging alternative. 1, 6
Site-Specific Considerations
Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections—ceftriaxone has superior efficacy and is the only reliably effective treatment for pharyngeal infections. 1, 2, 7
Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected. 1, 2
Gentamicin has only 20% cure rate for pharyngeal infections. 1
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, 8
Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy, which is inadequate. 1, 2
Never use oral cephalosporins as first-line agents due to documented treatment failures in Europe. 1
Ceftriaxone should not be mixed with calcium-containing solutions due to precipitation risk. 9
Special Populations
Pregnancy
Use the standard regimen: Ceftriaxone 500 mg IM + Azithromycin 1 g orally. 1, 2
Never use quinolones, tetracyclines, or doxycycline in pregnancy. 1, 2
Men Who Have Sex with Men (MSM)
Only use ceftriaxone-based regimens—never quinolones—due to higher prevalence of resistant strains. 1, 2
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 those requiring calcium-containing IV solutions. 9
Administer IV doses over 60 minutes in neonates to reduce risk of bilirubin encephalopathy. 9
Follow-Up Requirements
Patients treated with the recommended ceftriaxone 500 mg + azithromycin 1 g regimen do NOT need routine test-of-cure unless symptoms persist. 1, 2, 7
Consider retesting all patients at 3 months after treatment due to high reinfection risk (not to assess cure, but to detect reinfection). 1, 2
If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 1
Partner Management
All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen. 1, 2, 7
If last sexual contact was >60 days before diagnosis, treat the most recent partner. 7
Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1, 2
Expedited partner therapy with oral combination therapy (cefixime 400 mg + azithromycin 1 g) may be considered 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
Report the case to local public health officials within 24 hours. 1
Consult an infectious disease specialist. 1
Recommended salvage regimens include: Gentamicin 240 mg IM + Azithromycin 2 g orally, Spectinomycin 2 g IM + Azithromycin 2 g orally, or Ertapenem 1 g IM for 3 days. 1