What is the recommended treatment for a patient diagnosed with gonorrhea and possible chlamydia coinfection?

Treatment for Gonorrhea and Chlamydia Coinfection

Treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose for empiric coverage of both gonorrhea and chlamydia. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g PO (single dose) is the recommended first-line therapy when both gonorrhea and chlamydia exposure is suspected 1, 2
• This dual therapy achieves 99.1% cure rate for gonorrhea at all anatomic sites (cervical, urethral, rectal, pharyngeal) and provides single-dose chlamydia coverage 2
• Co-infection rates are extremely high at 40-50%, making presumptive treatment for both organisms essential 1, 3

Rationale for This Specific Regimen

• The 500 mg dose of ceftriaxone (not 250 mg) is now recommended due to rising minimum inhibitory concentrations and is particularly important for pharyngeal infections where cephalosporins have marked variability in tissue penetration 2, 4
• Azithromycin 1 g provides true single-dose therapy for chlamydia, eliminating the need for 7-day doxycycline courses and improving compliance 1
• Dual therapy also helps delay emergence of cephalosporin resistance through combination antimicrobial mechanisms 2

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Use cefixime 400 mg PO (single dose) + azithromycin 1 g PO (single dose) 1, 2
• Mandatory test-of-cure at 1 week is required with this regimen due to inferior efficacy compared to ceftriaxone 1, 2

For severe cephalosporin allergy:

• Azithromycin 2 g PO (single dose) can be used, but has only 93% efficacy for gonorrhea and causes gastrointestinal side effects in 35% of patients 1, 5
• Mandatory test-of-cure at 1 week is required 1, 2
• Alternative: Gentamicin 240 mg IM + azithromycin 2 g PO achieved 100% cure rate in clinical trials 2, 6

Critical Site-Specific Considerations

Pharyngeal gonorrhea requires special attention:

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal infections 1, 2
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal gonorrhea 2
• Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected 1, 3
• Gentamicin also has poor pharyngeal efficacy (only 20% cure rate) 2

Critical Pitfalls to Avoid

Never use these regimens:

• Quinolones (ciprofloxacin, ofloxacin) are absolutely contraindicated due to widespread resistance, despite historical 99.8% cure rates 1, 2, 3
• Azithromycin 1 g alone should never be used for gonorrhea due to insufficient 93% efficacy 1, 2
• Oral cephalosporins are no longer first-line agents due to documented treatment failures in Europe 2

Special Populations

Pregnancy:

• Use the same regimen: ceftriaxone 500 mg IM + azithromycin 1 g PO 1, 2, 7
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 1, 3, 8

Men who have sex with men (MSM):

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 2
• Do not use quinolones in this population 2
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 2

Follow-Up Requirements

Test-of-cure is NOT routinely needed:

• Patients treated with the recommended ceftriaxone 500 mg + azithromycin 1 g regimen do NOT require routine test-of-cure unless symptoms persist 1, 2, 7
• All patients should be retested at 3 months due to high reinfection risk (most are reinfections, not treatment failures) 1, 2, 7

When test-of-cure IS mandatory:

• Patients treated with cefixime-based regimens 1, 2
• Patients treated with azithromycin 2 g monotherapy 1, 2
• Patients with persistent symptoms after treatment 2

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 2
• Report the case to local public health officials within 24 hours 2
• Consult an infectious disease specialist 2
• Salvage regimens include gentamicin 240 mg IM + azithromycin 2 g PO or ertapenem 1 g IM for 3 days 2

Partner Management

All sexual partners from the preceding 60 days must be treated:

• Partners should receive the same dual therapy regimen (ceftriaxone 500 mg IM + azithromycin 1 g PO) 1, 2, 3
• Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1, 2, 3
• Expedited partner therapy with oral combination therapy (cefixime 400 mg + azithromycin 1 g) may be considered if partners cannot be linked to timely evaluation, but this is NOT recommended for MSM 2

Additional Screening

• Screen for syphilis with serology at the time of gonorrhea diagnosis 2
• Co-test for HIV given that gonorrhea facilitates HIV transmission 2, 4