What is the recommended antibiotic regimen for a patient diagnosed with gonorrhea?

Recommended Antibiotic Treatment for Gonorrhea

The first-line treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, administered together on the same day, preferably simultaneously and under direct observation. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g PO (single dose) is the only CDC-recommended first-line regimen for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 2, 3, 4, 5

• The 500 mg dose of ceftriaxone (rather than 250 mg) is particularly critical for pharyngeal infections, achieving 100% cure rate for urogenital gonorrhea and 90% for pharyngeal gonorrhea 2

• Dual therapy addresses both rising antibiotic resistance and the extremely high rate (40-50%) of chlamydial co-infection 1, 2

• Both medications should be administered simultaneously under direct observation to ensure compliance 3, 4, 5

Rationale for Dual Therapy

• Combination therapy improves treatment efficacy and delays emergence of cephalosporin resistance by using two antimicrobials with different mechanisms of action 1

• Azithromycin provides single-dose coverage for presumptive chlamydial co-infection, which is present in 40-50% of gonorrhea cases 1, 2

• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg PO (single dose) + Azithromycin 1 g PO (single dose) with mandatory test-of-cure at 1 week 1, 2

• This oral alternative has declining effectiveness due to rising cefixime MICs and should only be used when intramuscular ceftriaxone is not available 1

Severe Cephalosporin Allergy

• Azithromycin 2 g PO (single dose) with mandatory test-of-cure at 1 week 1, 6, 2

• This regimen has lower efficacy (93% cure rate) and causes significant gastrointestinal side effects 1, 2

• Consult an infectious disease specialist when treating patients with severe cephalosporin allergy, as data on alternative regimens are limited 6

• Gentamicin 240 mg IM + Azithromycin 2 g PO (single dose) is an alternative with 100% cure rate in clinical trials, though gastrointestinal adverse events are common 1, 7

Special Populations

Pregnant Women

• Ceftriaxone 500 mg IM + Azithromycin 1 g PO (single dose) is the recommended regimen 1, 2, 3, 4, 5

• Never use quinolones, tetracyclines, or doxycycline in pregnancy 1, 2

• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 3, 4, 5

Men Who Have Sex with Men (MSM)

• Ceftriaxone-based regimens are the only recommended treatment due to higher prevalence of resistant strains 1, 2

• Never use quinolones in MSM due to widespread resistance 1, 2

• Do not use expedited partner therapy (EPT) in MSM due to high risk of undiagnosed coexisting STDs or HIV 1, 2

Follow-Up and Test-of-Cure Requirements

• Patients treated with first-line ceftriaxone 500 mg + azithromycin 1 g do NOT need routine test-of-cure 1, 2, 3, 4, 5

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

  • Cefixime-based regimens 1, 2
  • Azithromycin 2 g monotherapy 1, 6, 2
  • Any alternative regimen in patients with cephalosporin allergy 6

• Culture is the preferred method for test-of-cure as it allows antimicrobial susceptibility testing 6

• Retest all patients 3 months after treatment due to high risk of reinfection (most post-treatment infections result from reinfection, not treatment failure) 2, 3, 4, 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 1, 2

• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1, 6

• Expedited partner therapy (EPT) with oral combination therapy (cefixime 400 mg + azithromycin 1 g) may be considered if partners cannot be linked to timely evaluation, but is NOT recommended for MSM 1, 2

Concurrent Testing Requirements

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1

• Test for HIV as gonorrhea facilitates HIV transmission 1, 2

• Test for chlamydia if not already treating presumptively 1

Treatment Failure Management

• If symptoms persist after treatment:

  • Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 6, 2
  • Report the case to local public health officials within 24 hours 1, 2
  • Consult an infectious disease specialist 1, 6, 2

• Recommended salvage regimens for suspected ceftriaxone treatment failure:

  • Gentamicin 240 mg IM + Azithromycin 2 g PO (single dose) 1, 2
  • Ertapenem 1 g IM for 3 days 1, 2

Critical Pitfalls to Avoid

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

• Never use azithromycin 1 g alone for gonorrhea treatment due to insufficient efficacy (only 93% cure rate) 1, 2

• Never use spectinomycin for pharyngeal infections due to poor efficacy (only 52% effective) 1, 2

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone 500 mg the only reliably effective treatment for pharyngeal sites 1, 2

• Most cases of ceftriaxone treatment failure involve the pharynx, not urogenital sites 1