Gonorrhea Treatment
Primary Recommendation
For uncomplicated gonorrhea of the cervix, urethra, rectum, or pharynx, treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose. 1, 2
This dual therapy regimen addresses both gonorrhea and presumptive chlamydial co-infection, which occurs in 40-50% of gonorrhea cases. 1, 2
Rationale for Dual Therapy
Dual therapy is essential because of rising antibiotic resistance patterns and the extremely high co-infection rate with chlamydia (40-50% of gonorrhea patients). 1, 2
The combination improves treatment efficacy and potentially delays emergence and spread of cephalosporin resistance. 1
Azithromycin is preferred over doxycycline for chlamydia coverage due to the convenience and compliance advantages of single-dose therapy, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin. 1
Alternative Regimens (When Ceftriaxone Unavailable)
Second-Line Option
Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose can be used if ceftriaxone is unavailable. 1, 3
Critical caveat: This regimen is less effective than ceftriaxone, particularly for pharyngeal infections, and requires mandatory test-of-cure at 1 week. 1, 3
Rising cefixime MICs have resulted in declining effectiveness for urogenital gonorrhea treatment. 1
Severe Cephalosporin Allergy
Azithromycin 2 g orally single dose is recommended for patients with severe cephalosporin allergy. 1, 3
This regimen has lower efficacy (only 93% cure rate) and high gastrointestinal side effects. 1
Mandatory test-of-cure at 1 week is required. 1
Alternative: Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally achieved 100% cure rate in clinical trials, but has poor pharyngeal efficacy (only 20% cure rate). 1, 4
Site-Specific Considerations
Pharyngeal Gonorrhea
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 alternative treatments and is strongly preferred. 1, 2
Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected. 1, 2
Gentamicin also has poor pharyngeal efficacy (only 20% cure rate in one study). 1
Most cases of ceftriaxone treatment failure involve the pharynx, not urogenital sites. 1
Special Populations
Pregnant Women
Use ceftriaxone 500 mg intramuscularly single dose PLUS azithromycin 1 g orally single dose. 1, 2
Ceftriaxone is the preferred cephalosporin. 1
Men Who Have Sex with Men (MSM)
Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains. 1, 3
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 due to higher likelihood of resistant strains. 1
Critical Pitfalls to Avoid
Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates. 1, 2, 5
Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy (only 93% cure rate). 1, 2
Never use oral cephalosporins as first-line agents due to documented treatment failures in Europe. 1
Ceftriaxone must not be administered simultaneously with calcium-containing IV solutions in any patient, and must never be used in neonates ≤28 days requiring calcium-containing IV solutions due to risk of fatal ceftriaxone-calcium precipitation. 6
Follow-Up Requirements
Routine Follow-Up
Patients treated with the recommended ceftriaxone plus azithromycin regimen do NOT need routine test-of-cure unless symptoms persist. 1, 2
All patients should be retested approximately 3 months after treatment due to high reinfection risk. 1, 2
Mandatory Test-of-Cure (1 Week Post-Treatment)
Required for patients receiving cefixime-based regimens. 1, 3
Required for patients receiving azithromycin 2 g monotherapy. 1, 3
Required for patients receiving gentamicin-based regimens. 1
Persistent Symptoms
If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 1, 3
If nucleic acid amplification testing is positive at follow-up, confirm with culture, and all positive cultures should undergo phenotypic antimicrobial susceptibility testing. 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
Salvage Regimens for Suspected Ceftriaxone Failure
Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally (single dose). 1
Spectinomycin 2 g intramuscularly PLUS azithromycin 2 g orally (single dose). 1
Ertapenem 1 g intramuscularly for 3 days. 1
Partner Management
All sexual partners from the preceding 60 days should be evaluated and treated with the same dual therapy regimen. 1, 2, 3
If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner. 3
Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1, 2
If partners' treatment cannot be ensured, consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g). 1