What is the recommended dose of Rocephin (ceftriaxone) for the treatment of uncomplicated gonorrhea?

Rocephin Dose for Gonorrhea

For uncomplicated gonorrhea, administer ceftriaxone 500 mg intramuscularly as a single dose, combined with azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days if chlamydial infection has not been excluded). 1

Current First-Line Regimen

The CDC updated its recommendations in 2020, increasing the ceftriaxone dose from 250 mg to 500 mg IM based on antimicrobial stewardship concerns and evolving resistance patterns. 1 This represents a significant change from historical guidelines that recommended 125-250 mg doses. 2

Key components of the regimen:

• Ceftriaxone 500 mg IM as a single dose 1
• Plus azithromycin 1 g orally as a single dose (preferred for dual therapy) 3
• Alternative: Doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded 1

Why the Dose Increased

The increase from 250 mg to 500 mg reflects:

• Antimicrobial stewardship principles to maintain therapeutic reserve 1
• Continued low incidence of ceftriaxone resistance but need for vigilance 1
• The goal of preventing emergence of resistance while maintaining high cure rates 3

Site-Specific Considerations

Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone the only acceptable first-line agent for this site. 3 The 500 mg dose provides superior efficacy for pharyngeal infections compared to lower doses or oral alternatives. 3

Urogenital and anorectal infections respond well to the 500 mg dose, with cure rates exceeding 95%. 1

Critical Concurrent Management

• Screen for syphilis with serology at the time of gonorrhea diagnosis 3
• Treat all sexual partners from the preceding 60 days; if last contact was >60 days before diagnosis, treat the most recent partner 3
• Instruct patients to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 3

What NOT to Use

Avoid these regimens due to inadequate efficacy or resistance:

• Quinolones (ciprofloxacin, ofloxacin) - widespread resistance 3
• Azithromycin 1 g alone - only 93% efficacy, inadequate 3
• Spectinomycin - only 52% efficacy for pharyngeal infections 3
• Cefixime as first-line - removed from primary recommendations in 2012 due to rising resistance 2, 4

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Cefixime 400 mg orally PLUS azithromycin 1 g orally (or doxycycline) 2
• Mandatory test-of-cure at 1 week 2
• Never use for pharyngeal infections - only 91% efficacy 4, 5

Severe Cephalosporin Allergy

For patients with severe cephalosporin allergy:

• Azithromycin 2 g orally as a single dose 2
• Mandatory test-of-cure at 1 week 2, 3

Special Populations

Pregnancy: Use the standard regimen (ceftriaxone 500 mg IM plus azithromycin 1 g orally); never use quinolones or tetracyclines. 3

Men who have sex with men (MSM): Only use ceftriaxone; never use quinolones due to higher prevalence of resistant strains in this population. 3

Neonates: Intravenous doses should be given over 60 minutes to reduce the risk of bilirubin encephalopathy; ceftriaxone is contraindicated in premature neonates and neonates ≤28 days requiring calcium-containing IV solutions. 6

Follow-Up Requirements

Patients treated with the recommended ceftriaxone 500 mg IM plus azithromycin 1 g regimen do not need routine test-of-cure unless symptoms persist. 3 However, consider retesting at 3 months due to high reinfection risk. 3

Common Pitfalls to Avoid

• Do not use lower doses (125 mg or 250 mg) - these are outdated recommendations 1
• Do not omit the second antimicrobial (azithromycin or doxycycline) - dual therapy helps prevent resistance and treats chlamydial coinfection 1
• Do not use cefixime for pharyngeal infections - inadequate efficacy 4, 5
• Do not use oral-only regimens for pharyngeal gonorrhea - ceftriaxone IM is required 3