What is the recommended treatment for gonorrhea, considering potential co-infection with chlamydia?

Gonorrhea Treatment

Treat uncomplicated gonorrhea with ceftriaxone 500 mg intramuscularly as a single dose, and add doxycycline 100 mg orally twice daily for 7 days if chlamydia co-infection has not been excluded. 1, 2, 3

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) is the foundation of gonorrhea treatment, achieving 99.1% cure rates for urogenital, anorectal, and pharyngeal infections 1, 4, 3
• Add doxycycline 100 mg orally twice daily for 7 days to cover chlamydia unless co-infection has been definitively ruled out 1, 2, 3
• Co-infection rates are extremely high (40-50% of gonorrhea patients also have chlamydia), making presumptive dual therapy essential 1, 2

Alternative Single-Dose Regimen (When Compliance is Uncertain)

• If you cannot ensure patient adherence to 7-day doxycycline, use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally (both single doses) 1, 4
• This regimen provides single-dose coverage for both infections but raises antimicrobial stewardship concerns due to azithromycin resistance patterns 3
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy 1, 4, 5

When Ceftriaxone is Unavailable

• Use cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) 1, 4
• Mandatory test-of-cure at 1 week is required with this regimen due to inferior efficacy compared to ceftriaxone 1, 4
• Cefixime has declining effectiveness with rising minimum inhibitory concentrations 4

Severe Cephalosporin Allergy

• First-line alternative: Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose), which achieved 100% cure rate in clinical trials 4, 6
• Second-line alternative: Azithromycin 2 g orally alone (single dose), but this has lower efficacy (93%) and causes gastrointestinal side effects in 35% of patients 1, 4, 5
• Spectinomycin 2 g IM has only 52% efficacy for pharyngeal infections—avoid if pharyngeal exposure is suspected 1, 2, 4

Critical Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2, 4
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections, with superior efficacy compared to all oral alternatives 1, 4
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 4

What NOT to Use

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite their historical 99.8% cure rates in 1998 7, 1, 2, 4
• Never use azithromycin 1 g alone—insufficient efficacy at only 93% 1, 4, 5
• Avoid spectinomycin for pharyngeal infections (only 52% effective) 1, 2, 4

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally (single dose) 1, 2, 4
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 2, 4, 8
• If azithromycin cannot be used, amoxicillin 500 mg three times daily for 7 days covers chlamydia 2

Men Who Have Sex with Men (MSM)

• Use only ceftriaxone-based regimens due to higher prevalence of resistant strains 4
• Never use quinolones in this population 4
• Do not use expedited partner therapy due to high risk of undiagnosed coexisting STDs or HIV 4

Follow-Up Requirements

• Patients treated with recommended ceftriaxone-based regimens do NOT need routine test-of-cure unless symptoms persist 1, 2, 4, 9
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy 1, 4
• All patients should be retested approximately 3 months after treatment due to high reinfection risk (most positive tests represent reinfection, not treatment failure) 1, 2, 9
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 9

When Symptoms Persist After Treatment

• Obtain culture with antimicrobial susceptibility testing immediately 2, 4
• Report suspected treatment failure to local public health officials within 24 hours 4
• Consult an infectious disease specialist 4
• Recommended salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days 4

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen 7, 1, 2, 4
• If partners cannot be linked to timely evaluation, consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g), except in MSM 4
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 7, 1, 2

Additional Testing at Diagnosis

• Screen for syphilis with serology at the time of gonorrhea diagnosis 4
• Perform HIV testing given that gonorrhea facilitates HIV transmission 4, 3