What is the recommended treatment for chlamydia and gonorrhea (Neisseria gonorrhoeae) infections in the throat?

Treatment for Pharyngeal Gonorrhea and Chlamydia

For throat infections with gonorrhea and chlamydia, use ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1, 2, 3

Why This Specific Regimen for Pharyngeal Infections

Pharyngeal gonorrhea is substantially more difficult to eradicate than urogenital or anorectal infections, requiring the most potent available therapy. 1, 4 Ceftriaxone is the only antibiotic that reliably achieves sustained bactericidal levels in pharyngeal tissue sufficient to cure >90% of throat infections. 1, 4

The Ceftriaxone Component (for Gonorrhea)

• Ceftriaxone 500 mg IM achieves 99.1% cure rates for pharyngeal gonorrhea, making it the only reliably effective option for throat infections. 5, 2, 3
• The 500 mg dose (not 250 mg) is now standard based on updated 2020 CDC guidelines that increased the dose due to antimicrobial stewardship concerns and evolving resistance patterns. 2, 3
• Never use oral cefixime for pharyngeal infections - it has inferior efficacy (only 93%) compared to ceftriaxone for throat sites and requires mandatory test-of-cure at 1 week. 1, 6, 5

The Doxycycline Component (for Chlamydia)

• Doxycycline 100 mg twice daily for 7 days is required for chlamydia coverage when treating pharyngeal infections, as chlamydial coinfection at genital sites occurs in 40-50% of gonorrhea cases. 4, 6, 1
• While azithromycin 1 g as a single dose is an alternative for chlamydia, doxycycline is preferred in the context of pharyngeal gonorrhea treatment to avoid using azithromycin (which has rising resistance for gonorrhea). 2, 3
• Azithromycin 1 g alone is insufficient for gonorrhea treatment (only 93% efficacy) and should never be used as monotherapy. 4, 5, 1

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) - these are completely ineffective due to widespread resistance, despite historical cure rates of 99.8% in 1998. 4, 5, 1
• Never use spectinomycin for pharyngeal infections - it has only 52% efficacy for throat gonorrhea and is unreliable. 4, 5, 1
• Never use gentamicin for pharyngeal infections - it has only 20% cure rate for throat gonorrhea in clinical studies. 5

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose (not doxycycline). 6, 5, 1
• Never use doxycycline, quinolones, or tetracyclines in pregnancy. 4, 5, 1
• Azithromycin 1 g orally or amoxicillin 500 mg three times daily for 7 days are safe alternatives for chlamydia coverage in pregnant women. 1

Severe Cephalosporin Allergy

• No reliably effective alternative exists for pharyngeal gonorrhea in patients with severe cephalosporin allergy. 2
• Azithromycin 2 g orally as a single dose can be attempted but has lower efficacy (93%) and high gastrointestinal side effects, with mandatory test-of-cure at 1 week. 5

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen, regardless of symptoms. 4, 6, 1
• Partners should receive ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 7 days (or azithromycin 1 g if pregnancy/contraindication to doxycycline). 6, 5, 1
• Patients must avoid all sexual intercourse until therapy is completed and both patient and all partners are asymptomatic. 4, 6, 1

Follow-Up Requirements

• Routine test-of-cure is NOT needed for patients treated with the recommended ceftriaxone regimen unless symptoms persist. 6, 5, 1
• Retest all patients at 3 months after treatment due to high reinfection risk (not to assess treatment failure, but to detect reinfection). 6, 5, 1
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing and consult an infectious disease specialist immediately. 5, 1
• Report suspected treatment failures to local public health officials within 24 hours. 5

Why Dual Therapy Is Essential

• Co-infection rates are extremely high, with 40-50% of gonorrhea patients also having chlamydia at genital sites, making presumptive treatment for both organisms essential. 6, 5
• Although chlamydial coinfection of the pharynx itself is unusual, coinfection at genital sites frequently occurs, necessitating treatment for both pathogens. 4
• Dual therapy also helps delay emergence and spread of cephalosporin resistance through different mechanisms of action. 5