What is the recommended management for gonorrhea?

Management of Gonorrhea

Primary Treatment Recommendation

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, with concurrent doxycycline 100 mg orally twice daily for 7 days if chlamydial co-infection has not been excluded. 1

This represents an important update from previous dual therapy recommendations. The CDC now recommends ceftriaxone monotherapy for gonorrhea treatment, with azithromycin reserved only for documented chlamydial co-infection, due to antimicrobial stewardship concerns and rising azithromycin resistance. 1

Treatment Regimens by Clinical Scenario

Standard Uncomplicated Gonorrhea (Urogenital, Anorectal, Pharyngeal)

First-line therapy:

• Ceftriaxone 500 mg IM single dose 1
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydia not excluded 1

Alternative regimen (when ceftriaxone unavailable):

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 2, 3
• Mandatory test-of-cure at 1 week required due to declining cefixime effectiveness 2, 3

Severe Cephalosporin Allergy

Treatment options:

• Azithromycin 2 g orally single dose (93% efficacy, high GI side effects) 2
• Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally single dose (100% cure rate in trials) 2, 4
• Mandatory test-of-cure at 1 week required 2

Pregnant Patients

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose 2, 3, 5, 6
• Never use quinolones or tetracyclines in pregnancy 2, 3
• Retest in third trimester unless recently treated 5, 6

Men Who Have Sex with Men (MSM)

• Only ceftriaxone is recommended due to higher prevalence of resistant strains 2, 3
• Never use quinolones in this population 2, 3
• Do not use patient-delivered partner therapy due to high risk of undiagnosed co-infections or HIV 2

Site-Specific Considerations

Pharyngeal Gonorrhea

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal infections 2, 3
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all alternatives 2
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 2
• Gentamicin has only 20% cure rate for pharyngeal infections 2

Critical Pitfalls to Avoid

Never use the following due to widespread resistance:

• Quinolones (ciprofloxacin, ofloxacin) - no longer recommended despite historical 99.8% cure rates 2, 3
• Azithromycin 1 g alone - insufficient efficacy (only 93%) 2

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 2, 3, 7
• If last sexual contact was >60 days before diagnosis, treat the most recent partner 7
• Partners should receive the same dual therapy regimen 2
• Patients should avoid sexual intercourse until therapy is completed and both partners are asymptomatic 2
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 2

Follow-Up Requirements

Test-of-Cure

• Not needed for uncomplicated urogenital or rectal gonorrhea treated with recommended ceftriaxone regimen 2, 3, 5, 6
• Mandatory at 1 week for patients receiving cefixime or azithromycin monotherapy 2
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 2, 3

Retesting for Reinfection

• Retest all patients 3 months after treatment due to high risk of reinfection 2, 3, 5, 6
• Most repeat infections result from reinfection, not treatment failure 5, 6

Concurrent Testing

• Screen for syphilis with serology at time of gonorrhea diagnosis 2, 7
• Co-test for HIV given facilitation of HIV transmission by gonorrhea 2

Treatment Failure Management

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 2, 3
• Report the case to local public health officials within 24 hours 2
• Consult an infectious disease specialist 2, 3

Salvage regimens for suspected ceftriaxone failure:

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

Note: Most ceftriaxone treatment failures involve pharyngeal sites, not urogenital sites 2

Rationale for Current Recommendations

The shift from mandatory dual therapy (ceftriaxone plus azithromycin) to ceftriaxone monotherapy reflects:

• Continued low incidence of ceftriaxone resistance 1
• Increased incidence of azithromycin resistance 1
• Antimicrobial stewardship concerns about impact on commensal organisms 1
• Ceftriaxone achieves 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 2

However, dual therapy remains appropriate when chlamydial co-infection has not been excluded, as co-infection occurs in 40-50% of gonorrhea patients. 2, 3