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

Gonorrhea Treatment

Primary Recommended Regimen

For uncomplicated gonorrhea, treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days (if chlamydial coinfection has not been excluded). 1

This represents the most current CDC recommendation, updated from the previous dual therapy with azithromycin due to antimicrobial stewardship concerns and rising azithromycin resistance. 2

Rationale for Current Regimen

• Ceftriaxone 500 mg (increased from the previous 250 mg dose) achieves 99.1% cure rate for urogenital/anorectal gonorrhea and 90-100% for pharyngeal infections. 3, 1

• The higher 500 mg dose is particularly critical for pharyngeal infections, where cephalosporins show marked variability in tissue penetration, with nearly 90% being protein-bound in tonsillar tissue. 3, 1

• Doxycycline replaces azithromycin as the preferred chlamydia coverage due to antimicrobial stewardship concerns and the 40-50% coinfection rate. 1, 2

• Azithromycin 1 g alone has only 93% efficacy against gonorrhea and should never be used as monotherapy. 3

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone cannot be administered, use cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose, with mandatory test-of-cure at 1 week. 3, 1, 4

• Cefixime has declining effectiveness due to rising MICs and is less effective for pharyngeal infections than ceftriaxone. 3

• The oral regimen requires follow-up testing because of lower efficacy. 1

Severe Cephalosporin Allergy

For patients with documented severe cephalosporin allergy, use azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week and consultation with an infectious disease specialist. 1, 5

• This regimen has only 93% efficacy and causes significant gastrointestinal side effects (35.3% of patients, with 2.9% severe). 3, 6

• Alternative option: Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally achieved 100% cure rate in clinical trials, including 10/10 pharyngeal infections. 3, 7

• Culture with antimicrobial susceptibility testing is essential for all alternative regimens. 5

Special Populations

Pregnant Women

Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally (single dose). 1

• Never use quinolones, tetracyclines, or doxycycline in pregnancy. 3, 1

• Erythromycin or amoxicillin should be used for chlamydia coverage instead of doxycycline. 5

Men Who Have Sex with Men (MSM)

Use only ceftriaxone-based regimens; never use quinolones due to higher prevalence of resistant strains. 3, 1

• Do not use expedited partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV. 1

Test-of-Cure Requirements

• Patients treated with first-line ceftriaxone 500 mg do NOT need routine test-of-cure. 1

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

  • Cefixime-based regimens 3, 1
  • Azithromycin 2 g monotherapy 1
  • Any alternative regimen 5

• Retest all patients at 3 months due to high reinfection rates (most post-treatment infections are reinfection, not treatment failure). 1

• Culture is preferred over NAAT for test-of-cure as it allows antimicrobial susceptibility testing. 5

Partner Management

All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen for both gonorrhea and chlamydia. 3, 1

• Expedited partner therapy (EPT) with oral cefixime 400 mg plus azithromycin 1 g may be used if partners cannot access timely evaluation. 1

• EPT is contraindicated in MSM. 1

• Patients must abstain from sexual intercourse until therapy is completed and both partners are asymptomatic. 3

Concurrent Testing Requirements

Screen for syphilis with serology and HIV at the time of gonorrhea diagnosis, as gonorrhea facilitates HIV transmission. 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) due to widespread resistance. 3, 1, 2

• Never use azithromycin 1 g alone for gonorrhea (only 93% efficacy). 3, 1

• Never use spectinomycin for pharyngeal infections (only 52% effective). 3, 1

• Do not substitute tablets/capsules for suspension in pediatric otitis media, as suspension achieves higher peak blood levels. 4

• Ceftriaxone is strongly preferred over cefixime for pharyngeal infections due to superior efficacy. 3

Treatment Failure Management

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately. 3, 1

• Report to local public health officials within 24 hours. 3, 1

• Consult an infectious disease specialist. 3, 1, 5

• Salvage regimens include:

  • Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 3, 1
  • Ertapenem 1 g IM for 3 days 3, 1

• Most ceftriaxone treatment failures involve pharyngeal sites, not urogenital sites. 3