What is the recommended treatment for gonorrhea?

Treatment for Gonorrhea

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 coinfection has not been excluded. 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the first-line monotherapy for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. 1
• Add doxycycline 100 mg orally twice daily for 7 days if Chlamydia trachomatis infection has not been ruled out, as 40-50% of gonorrhea patients have concurrent chlamydial infection. 2, 1
• This represents an important update from older dual therapy recommendations that routinely included azithromycin, driven by antimicrobial stewardship concerns and rising azithromycin resistance. 1

Alternative Regimens When Ceftriaxone Is Unavailable

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose can be used when ceftriaxone is not available. 2, 3
• Mandatory test-of-cure at 1 week is required with the cefixime regimen due to declining effectiveness related to rising minimum inhibitory concentrations (MICs). 2, 3
• Cefixime has inferior efficacy compared to ceftriaxone, with only 97.1% cure rate versus 99.1% for ceftriaxone. 4

Severe Cephalosporin Allergy

• For patients with severe cephalosporin allergy, use azithromycin 2 g orally single dose with mandatory test-of-cure at 1 week. 3
• This regimen has lower efficacy (only 93%) and causes significant gastrointestinal side effects. 3
• Alternative salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) or ertapenem 1 g IM for 3 days. 2, 3

Special Populations

Pregnant Women

• Use the same recommended regimen: ceftriaxone 500 mg IM PLUS azithromycin 1 g orally (if chlamydia not excluded). 2, 5, 6
• Never use quinolones or tetracyclines in pregnancy. 2, 3
• Retest in the third trimester unless recently treated. 5, 6

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains in this population. 2, 3
• Never use quinolones in MSM due to widespread resistance. 3

Neonates

• Administer intravenous doses over 60 minutes (not 30 minutes) to reduce risk of bilirubin encephalopathy. 7
• Do not use calcium-containing diluents or administer simultaneously with calcium-containing IV solutions due to precipitation risk. 7

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 2, 3
• Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives. 3
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for this site. 3
• Gentamicin also has poor pharyngeal efficacy (only 20% cure rate). 3

Critical Antimicrobial Resistance Considerations

• Quinolones (ciprofloxacin, ofloxacin) are no longer recommended for gonorrhea treatment due to widespread resistance, despite historical cure rates of 99.8%. 2, 3, 1
• Azithromycin 1 g alone is insufficient for gonorrhea treatment with only 93% efficacy. 3
• Dual therapy with two antimicrobials having different mechanisms of action was historically recommended to delay emergence of cephalosporin resistance, but current guidelines favor ceftriaxone monotherapy with selective chlamydia coverage. 2, 1

Follow-Up and Test-of-Cure

• Patients treated with the recommended ceftriaxone regimen do not need routine test-of-cure unless symptoms persist. 2, 3, 5
• All patients should be retested 3 months after treatment due to high risk of reinfection (not treatment failure). 2, 3, 5
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 2, 3

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately. 3
• Report the case to local public health officials within 24 hours and consult an infectious disease specialist. 3
• Most cases of ceftriaxone treatment failure involve pharyngeal (not urogenital) sites. 3
• Recommended salvage regimens: gentamicin 240 mg IM PLUS azithromycin 2 g orally, spectinomycin 2 g IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days. 3

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days for both gonorrhea and chlamydia. 2, 3
• Partners should receive the same dual therapy regimen. 3
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 8, 3
• Expedited partner therapy (patient-delivered medication) may be considered when partners cannot be linked to timely evaluation, using oral combination therapy (cefixime 400 mg plus azithromycin 1 g). 3
• Do not use expedited partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV. 3

Additional Clinical Considerations

• Screen for syphilis with serology and HIV at the time of gonorrhea diagnosis, as gonorrhea facilitates HIV transmission. 3
• If nucleic acid amplification testing is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing. 3
• The dose increase from 250 mg to 500 mg ceftriaxone reflects evolving resistance patterns and ensures adequate treatment margins. 1