What is the recommended management for a patient diagnosed with gonorrhea?

Management of Gonorrhea

Primary Treatment Regimen

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

This represents an update from the previous dual therapy recommendation of ceftriaxone 250 mg plus azithromycin 1 g, reflecting concerns about antimicrobial stewardship and rising azithromycin resistance while maintaining efficacy against gonorrhea. 1

Rationale for Current Regimen

• The higher 500 mg dose of ceftriaxone is particularly important for pharyngeal infections, where extended-spectrum cephalosporins have marked variability in clearance and half-life within pharyngeal tissues. 2
• Dual therapy addresses the high prevalence of chlamydial coinfection (40-50% of gonorrhea patients) and helps delay emergence of cephalosporin resistance. 2
• Doxycycline is now preferred over azithromycin for chlamydial coverage due to antimicrobial stewardship concerns and increasing azithromycin resistance. 1

Sites of Infection Covered

This regimen effectively treats uncomplicated gonococcal infections of:

• Cervix, urethra, and rectum 3
• Pharynx (pharyngeal infections are more difficult to eradicate than urogenital or anorectal sites) 3, 2

Alternative Regimens

When Ceftriaxone is Unavailable

Cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose, with mandatory test-of-cure at 1 week. 3, 2

• Cefixime is less effective than ceftriaxone, particularly for pharyngeal infections, due to rising minimum inhibitory concentrations. 2
• Test-of-cure should ideally be performed with culture or NAAT if culture is unavailable. 3

For Severe Cephalosporin Allergy

Azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week. 3, 4

• This regimen has lower efficacy (93% cure rate) and causes significant gastrointestinal side effects. 2, 5
• Consult an infectious disease specialist when treating patients with severe cephalosporin allergy. 4

Alternative Non-Cephalosporin Option

Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally (single dose) achieved 100% cure rate in clinical trials for urogenital gonorrhea. 6, 2

• However, gentamicin has poor efficacy for pharyngeal infections (only 20% cure rate). 2
• Gastrointestinal adverse events are common with this regimen. 6

Special Populations

Pregnant Women

Use ceftriaxone 500 mg intramuscularly PLUS azithromycin 1 g orally (single dose). 2, 7

• Never use quinolones, tetracyclines, or doxycycline in pregnancy. 3, 4
• For chlamydial coverage in pregnancy, use erythromycin or amoxicillin instead of doxycycline. 3, 4
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated. 7

Men Who Have Sex with Men (MSM)

Use only ceftriaxone-based regimens; never use quinolones due to higher prevalence of resistant strains. 3, 2, 8

• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV. 2

Pediatric Patients

For children weighing >45 kg, use adult dosing regimens. 3

Follow-Up and Test-of-Cure

Routine Follow-Up

Patients treated with recommended first-line regimens (ceftriaxone 500 mg) do NOT need routine test-of-cure. 3, 1

Mandatory Test-of-Cure Required For:

• Patients treated with cefixime-based regimens (at 1 week) 3, 2
• Patients treated with azithromycin 2 g monotherapy for cephalosporin allergy (at 1 week) 3, 4
• Patients with persistent symptoms after treatment 3

Retesting for Reinfection

All patients should be retested 3 months after treatment due to high reinfection rates. 3, 7

• Most post-treatment infections result from reinfection rather than treatment failure. 3
• If patients don't return at 3 months, test whenever they next seek care within 12 months. 3

Treatment Failure Management

If Symptoms Persist After Treatment:

1. Obtain culture for N. gonorrhoeae with antimicrobial susceptibility testing immediately. 3, 2
2. Report the case to local public health officials within 24 hours. 3, 2
3. Consult an infectious disease specialist. 3, 4

Salvage Regimens for Treatment Failure:

• Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally (single dose) 2
• Ertapenem 1 g intramuscularly for 3 days 2
• If NAAT is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing. 2

Partner Management

Evaluation and Treatment of Partners

All sex partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia. 3, 2

• If the patient's last sexual contact was >60 days before symptom onset or diagnosis, treat the most recent partner. 3, 8
• Partners should receive the same dual therapy regimen. 2
• Patients must avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic. 3, 4

Expedited Partner Therapy (EPT)

If partners cannot be linked to timely evaluation, consider EPT using oral combination therapy (cefixime 400 mg plus azithromycin 1 g). 3, 2

• EPT is NOT recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV. 3, 2
• EPT should be accompanied by educational materials about symptoms and the importance of seeking clinical evaluation. 3

Concurrent Testing Requirements

Screen for syphilis with serology and HIV at the time of gonorrhea diagnosis. 2

• Gonorrhea facilitates HIV transmission. 1
• All patients with sexually transmitted urethritis or cervicitis should have serologic testing for syphilis and appropriate cultures for gonorrhea. 3

Critical Pitfalls to Avoid

Never Use These Regimens:

• Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) - widespread resistance makes them completely ineffective. 3, 2, 1
• Azithromycin 1 g alone - insufficient efficacy (only 93% cure rate). 3, 2
• Spectinomycin for pharyngeal infections - only 52% effective for pharyngeal gonorrhea. 3, 2

Important Caveats:

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections; ceftriaxone is the only reliably effective treatment. 2
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites. 2
• Azithromycin 2 g causes gastrointestinal distress in 35.3% of patients (moderate in 10.1%, severe in 2.9%). 5
• The capacity for N. gonorrhoeae culture is declining rapidly due to widespread NAAT use, but culture capacity must be maintained to monitor antimicrobial resistance. 3