What is the recommended treatment for a patient diagnosed with chlamydia and gonorrhea, considering potential allergies, pregnancy status, and local resistance patterns?

Treatment for Chlamydia and Gonorrhea

For uncomplicated chlamydia and gonorrhea co-infection, treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days, which provides superior efficacy compared to azithromycin-based regimens and addresses the high co-infection rate of 40-50%. 1

Primary Treatment Regimen

Standard dual therapy consists of:

• Ceftriaxone 500 mg IM single dose for gonorrhea 1
• Doxycycline 100 mg orally twice daily for 7 days for chlamydia 2, 1, 3

This combination is preferred because:

• Ceftriaxone achieves 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1
• Doxycycline provides more reliable chlamydia coverage than single-dose azithromycin 1
• Co-infection occurs in 40-50% of gonorrhea cases, making presumptive treatment for both organisms essential 1

Alternative Regimens

If ceftriaxone is unavailable:

• Cefixime 400 mg orally single dose PLUS doxycycline 100 mg orally twice daily for 7 days 2, 1
• Mandatory test-of-cure at 1 week is required with this regimen 1, 4

For patients preferring single-dose therapy:

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose 2, 1
• Note: Azithromycin alone has only 93% efficacy for gonorrhea and should never be used as monotherapy 1, 5

For severe cephalosporin allergy:

• Azithromycin 2 g orally single dose for gonorrhea PLUS doxycycline 100 mg orally twice daily for 7 days for chlamydia 1, 4
• Mandatory test-of-cure at 1 week is required 1, 4
• This regimen has lower efficacy (93%) and high gastrointestinal side effects 1

Special Population Considerations

Pregnancy:

• Ceftriaxone 500 mg IM single dose PLUS azithromycin 1 g orally single dose 2, 1, 5
• Alternative for chlamydia: Amoxicillin 500 mg orally three times daily for 7 days 2
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 2, 1
• Test-of-cure is mandatory 4 weeks after treatment in pregnancy 3

Men who have sex with men (MSM):

• Use only ceftriaxone-based regimens due to higher prevalence of resistant strains 1
• Never use quinolones in this population 1
• Screen at least annually 3

Children weighing <45 kg:

• Gonorrhea: Ceftriaxone 25-50 mg/kg IM single dose (not to exceed 250 mg) 2
• Chlamydia: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses for 14 days 2

Children ≥8 years and weighing ≥45 kg:

• Same treatment as adults 2

Site-Specific Considerations

Pharyngeal infections:

• Ceftriaxone is the only reliably effective treatment, with superior efficacy compared to oral alternatives 1, 5
• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 5
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 1, 5, 4
• Gentamicin has only 20% cure rate for pharyngeal infections 1

Rectal and urogenital infections:

• Standard dual therapy is effective at all sites 1

Critical Pitfalls to Avoid

Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance 2, 1, 4

Never use azithromycin 1 g alone for gonorrhea - it has only 93% efficacy 1, 5

Never use oral cephalosporins as first-line agents - documented treatment failures have occurred in Europe 1

Never skip chlamydia coverage when treating gonorrhea - co-infection rates are 40-50% 1

Follow-Up Requirements

Routine follow-up:

• Patients treated with recommended regimens (ceftriaxone + doxycycline or azithromycin) do not need routine test-of-cure 1, 5
• Rescreen all patients 3 months after treatment due to high reinfection rates 2, 1, 3

Mandatory test-of-cure at 1 week required for:

• Cefixime-based regimens 1, 4
• Azithromycin 2 g monotherapy 1, 4
• Alternative regimens 4
• All pregnant patients (4 weeks after treatment) 3

If symptoms persist after treatment:

• Obtain culture for N. gonorrhoeae with antimicrobial susceptibility testing 1, 5, 4
• Report to local public health officials within 24 hours 1, 4
• Consult infectious disease specialist 1, 4

Treatment Failure Management

For suspected ceftriaxone treatment failure:

• Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1, 4
• Spectinomycin 2 g IM PLUS azithromycin 2 g orally 1
• Ertapenem 1 g IM for 3 days 1, 4
• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 4

Partner Management

All sexual partners from the preceding 60 days must be evaluated and treated 1, 5, 4

Partners should receive the same dual therapy regimen for both gonorrhea and chlamydia 1

Expedited partner therapy:

• Consider oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1, 4
• Not recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 5, 4

Resistance Considerations

Local resistance patterns should guide treatment decisions:

• Quinolone resistance is widespread in the US 2, 1
• Rising cefixime MICs have resulted in declining effectiveness 1
• Dual therapy with different mechanisms of action helps delay emergence of cephalosporin resistance 1

Screen for syphilis and HIV at time of gonorrhea diagnosis - gonorrhea facilitates HIV transmission 1