What is the standard treatment for gonorrhea (sexually transmitted infection)?

Standard Treatment for Gonorrhea

The standard treatment for uncomplicated gonorrhea is ceftriaxone 250 mg intramuscularly PLUS azithromycin 1 g orally, both given as single doses on the same day, preferably simultaneously and under direct observation. 1, 2, 3, 4

Primary Dual Therapy Regimen

• Ceftriaxone 250 mg IM (single dose) + Azithromycin 1 g PO (single dose) is the only recommended first-line treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 2, 3, 4
• Both medications should be administered together on the same day, preferably simultaneously and under direct observation 3, 4
• This regimen achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1

Rationale for Dual Therapy

• Rising antibiotic resistance necessitates combination therapy with two antimicrobials having different mechanisms of action to improve treatment efficacy and potentially delay emergence of cephalosporin resistance 1, 2
• Chlamydial co-infection occurs in 40-50% of gonorrhea patients, making presumptive treatment for both organisms essential 1, 2
• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1, 5

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg PO (single dose) + Azithromycin 1 g PO (single dose) 1, 2, 6
  • Mandatory test-of-cure at 1 week is required with this regimen due to declining effectiveness of cefixime related to rising MICs 1, 2
  • Cefixime has only 97.1% efficacy compared to ceftriaxone's 99.1% 7

Severe Cephalosporin Allergy

• Azithromycin 2 g PO (single dose) with mandatory test-of-cure at 1 week 1
  • This regimen has lower efficacy (93%) and high gastrointestinal side effects 1, 5
• Gentamicin 240 mg IM + Azithromycin 2 g PO (single dose) is an alternative with 100% cure rate in clinical trials 1, 8
  • However, gentamicin has poor pharyngeal efficacy (only 20% cure rate) 1

Critical Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 7
• Ceftriaxone is the only reliably effective treatment for pharyngeal infections and is strongly preferred over oral alternatives 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for this site 1

Special Populations

Pregnant Women

• Use the same dual therapy: Ceftriaxone 250 mg IM + Azithromycin 1 g PO 1, 2, 3, 4
• Never use quinolones or tetracyclines in pregnancy 1, 7
• Ceftriaxone is the preferred cephalosporin 1

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1, 2
• Never use quinolones in this population 1
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates 1, 7, 2
• Never use azithromycin 1 g alone for gonorrhea—it is insufficient with only 93% efficacy 1
• Never substitute tablets/capsules for suspension when treating otitis media, as suspension achieves higher peak blood levels 6
• Oral cephalosporins are no longer first-line agents due to documented treatment failures in Europe 1

Follow-Up Requirements

• No routine test-of-cure needed for patients treated with the recommended ceftriaxone plus azithromycin regimen 1, 2, 3, 4
• Mandatory test-of-cure at 1 week for patients receiving cefixime-based regimens or azithromycin monotherapy 1, 2
• Retest all patients at 3 months after treatment due to high risk of reinfection 1, 2, 3, 4
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing 1

Treatment Failure Management

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 2
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1, 2
• Recommended salvage regimens include:
  • Gentamicin 240 mg IM + Azithromycin 2 g PO (single dose) 1, 8
  • Spectinomycin 2 g IM + Azithromycin 2 g PO 1
  • Ertapenem 1 g IM for 3 days 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days 1, 2
• Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 1
• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1
• Expedited partner therapy with oral combination therapy (cefixime 400 mg + azithromycin 1 g) may be considered when partners cannot be linked to timely evaluation, but is not recommended for MSM 1

Additional Screening

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1
• Co-test for HIV given the facilitation of HIV transmission by gonorrhea 1