Ceftriaxone 500mg IM + Doxycycline 100mg BID for Gonorrhea
No, this regimen is NOT recommended—you must use azithromycin 1g orally as a single dose instead of doxycycline for gonorrhea treatment. 1, 2
Why Azithromycin is Required, Not Doxycycline
The CDC and American College of Physicians explicitly recommend ceftriaxone 500mg IM PLUS azithromycin 1g orally as a single dose as the standard treatment regimen for gonorrhea. 1
Azithromycin is given as a single 1g oral dose (not doxycycline) to address potential chlamydial coinfection and to potentially delay emergence of cephalosporin resistance. 1
While doxycycline 100mg BID for 7 days is effective for chlamydia treatment, it is not the preferred partner agent for gonorrhea because azithromycin provides single-dose convenience and may help prevent resistance development. 1
Evidence Comparing the Two Regimens
A 2013 retrospective study found no significant difference in retreatment rates between ceftriaxone plus azithromycin versus ceftriaxone plus doxycycline (adjusted hazard ratio 0.88,95% CI 0.69-1.12), suggesting doxycycline may be a reasonable alternative. 3
However, in the subanalysis of patients retested within 30 days, all retreated patients had received the doxycycline regimen, raising concerns about its efficacy. 3
Historical data from 1990 supports ceftriaxone 250mg IM plus doxycycline 100mg BID for 7 days for presumptive chlamydial coinfection treatment, but this predates current resistance patterns and guideline updates. 4
The Correct Regimen
Use ceftriaxone 500mg IM as a single dose PLUS azithromycin 1g orally as a single dose. 1
This combination has superior efficacy compared to all oral alternatives and is the only acceptable first-line regimen, particularly for pharyngeal gonorrhea which is significantly more difficult to eradicate. 1
The 500mg dose represents an increase from older 250mg guidelines due to antimicrobial stewardship concerns and evolving resistance patterns. 1
Critical Concurrent Management
Screen for syphilis with serology at the time of gonorrhea diagnosis. 1
Treat all sexual partners from the preceding 60 days; if last contact was >60 days before diagnosis, treat the most recent partner. 1
Instruct patients to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1
Follow-Up Requirements
Patients treated with the recommended ceftriaxone 500mg IM + azithromycin 1g regimen do not need routine test-of-cure unless symptoms persist. 1
Consider retesting at 3 months due to high reinfection risk. 1
Common Pitfall to Avoid
Do not substitute doxycycline for azithromycin in gonorrhea treatment—the single-dose azithromycin regimen is preferred for compliance, resistance prevention, and guideline adherence. 1, 3