What is the treatment for a rectal swab positive for gonorrhea?

Treatment for Rectal Gonorrhea

Treat rectal gonorrhea with ceftriaxone 500 mg IM as a single dose PLUS azithromycin 1 g orally as a single dose, or alternatively doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the recommended dual therapy for uncomplicated rectal gonorrhea. 1, 2
• The CDC updated the ceftriaxone dose from 250 mg to 500 mg in 2020 to maintain efficacy against evolving resistance patterns. 2
• If chlamydial infection has not been excluded, doxycycline 100 mg orally twice daily for 7 days can be substituted for azithromycin to address presumptive chlamydial coinfection. 1, 2
• Dual therapy is essential because coinfection with Chlamydia trachomatis occurs in 40-50% of gonorrhea cases. 1
• Ceftriaxone achieves 99.1% cure rates for anorectal gonorrhea and is effective at all anatomic sites (cervical, urethral, rectal, pharyngeal) with single-dose administration. 1, 3

Alternative Regimens When Ceftriaxone Is Unavailable

• Cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) with mandatory test-of-cure at 1 week is the alternative when ceftriaxone cannot be administered. 1, 4
• This oral regimen is less effective than ceftriaxone due to declining cefixime susceptibility and rising minimum inhibitory concentrations. 1, 4
• Test-of-cure is mandatory because oral cephalosporins have documented treatment failures in Europe. 1

Severe Cephalosporin Allergy

• For patients with anaphylactic penicillin allergy or severe cephalosporin allergy, use azithromycin 2 g orally as a single dose with mandatory test-of-cure at 1 week. 1, 5
• This regimen has 96-99% efficacy but causes frequent gastrointestinal side effects. 5, 4
• Never use azithromycin 1 g alone for gonorrhea—it cures only 93% of infections and is insufficient as monotherapy. 1, 5
• Gentamicin 240 mg IM (single dose) PLUS azithromycin 2 g orally (single dose) is another alternative with 100% cure rates in clinical trials, though it has poor pharyngeal efficacy. 1

Critical Management Components

Test-of-Cure Requirements

• Routine test-of-cure is not necessary for patients treated with the recommended ceftriaxone-based regimen who become asymptomatic. 1, 4
• Test-of-cure is mandatory at 1 week when using alternative regimens (cefixime, azithromycin monotherapy, or gentamicin). 1, 5
• If nucleic acid amplification testing is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing. 1

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia, regardless of symptoms. 1, 4
• Partners should receive the same dual therapy regimen. 1
• Patients and partners must abstain from sexual intercourse until therapy is completed and both are asymptomatic. 1, 4
• Expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) may be considered when partners cannot be linked to timely evaluation, but this is not recommended for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV. 1

Special Populations

Men Who Have Sex with Men (MSM)

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

Pregnant Women

• Use the same ceftriaxone 500 mg IM dose as non-pregnant patients. 1, 4
• Absolutely avoid quinolones and tetracyclines during pregnancy. 1, 4
• If ceftriaxone cannot be used due to severe allergy, azithromycin 2 g orally is the only option, though data in pregnancy are limited. 5

HIV-Infected Patients

• Use identical treatment regimens as HIV-negative patients. 4
• Treatment is particularly vital because gonococcal infection increases HIV shedding and transmission risk. 4

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite historical 99.8% cure rates. 1, 5, 6
• Never use azithromycin 1 g as monotherapy—it is insufficiently effective with only 93% cure rates. 1, 5
• Do not withhold cephalosporins based solely on patient-reported penicillin allergy without assessing severity—most patients can safely receive ceftriaxone. 5
• Do not skip test-of-cure when using alternative regimens—treatment failure rates are higher with non-cephalosporin regimens. 5
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided if pharyngeal infection is present. 1

Treatment Failure Management

• If symptoms persist after recommended treatment, obtain culture with antimicrobial susceptibility testing immediately. 1, 4
• Report treatment failures to local public health officials within 24 hours. 1
• Consult an infectious disease specialist. 1, 4
• Recommended salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) or ertapenem 1 g IM for 3 days. 1

Additional Screening Recommendations

• 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, 6
• Consider retesting all patients 3 months after treatment due to high risk of reinfection. 1