What is the recommended treatment for a patient with a positive Neisseria (N.) gonorrhea RNA test result via Transcription-Mediated Amplification (TMA)?

Treatment for Positive Neisseria Gonorrhoeae RNA, TMA

Primary Recommendation

Treat with 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, 3

Rationale for Dual Therapy

• Dual therapy is mandatory due to rising antimicrobial resistance patterns and the need to improve treatment efficacy while potentially delaying emergence of cephalosporin resistance 1
• This regimen also provides coverage for presumptive chlamydial co-infection, which occurs in 40-50% of gonorrhea cases 1
• Azithromycin 1 g alone is insufficient for gonorrhea treatment, with only 93% efficacy 1
• The combination achieves 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 1
• Mandatory test-of-cure at 1 week is required with this regimen 1

For severe cephalosporin allergy:

• Azithromycin 2 g orally single dose (lower efficacy at 93%, high GI side effects) 1
• Mandatory test-of-cure at 1 week is required 1
• Alternative: Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally single dose (100% cure rate in trials) 1

Critical Site-Specific Considerations

Pharyngeal infections are significantly more difficult to eradicate:

• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal gonorrhea 1
• The 500 mg dose is particularly important because extended-spectrum cephalosporins have marked variability in clearance within pharyngeal tissues 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 1
• Gentamicin has poor pharyngeal efficacy (only 20% cure rate) 1

Essential Co-Management

All patients must be:

• Tested for chlamydia, syphilis, and HIV at the time of gonorrhea diagnosis 4, 1
• If chlamydial NAAT is negative at time of treatment, separate chlamydia treatment is not needed 4
• If chlamydial results are unavailable or non-NAAT was used, treat for both infections 4

Partner Management

All sexual partners from the preceding 60 days must be:

• Evaluated and treated with the same dual therapy regimen 1
• Patients should avoid sexual intercourse until therapy is completed and both partners are asymptomatic 1
• Consider expedited partner therapy with oral combination (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1
• Exception: Do NOT use expedited partner therapy for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV 1

Special Populations

Pregnant women:

• Use the same recommended dual therapy: ceftriaxone 500 mg IM plus azithromycin 1 g orally 1, 2
• Never use quinolones or tetracyclines in pregnancy 1
• Retest in third trimester unless recently treated 2, 3

Men who have sex with men (MSM):

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1
• Never use quinolones in this population 4, 1

Patients with recent foreign travel:

• Use ceftriaxone-based regimen only due to higher resistance rates internationally 1

Follow-Up Requirements

Routine test-of-cure is NOT needed for patients treated with recommended regimens 1, 2

Test-of-cure IS mandatory for:

• Patients receiving cefixime plus azithromycin (at 1 week) 1
• Patients receiving azithromycin 2 g monotherapy (at 1 week) 1
• Patients with persistent symptoms after treatment 1

Retesting at 3 months:

• All patients should be retested 3 months after treatment due to high reinfection rates 1, 2

Treatment Failure Management

If treatment failure is suspected:

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

Recommended salvage regimens:

• Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1
• Ertapenem 1 g IM for 3 days 1
• Spectinomycin 2 g IM PLUS azithromycin 2 g orally (avoid for pharyngeal infections) 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance 1
• Never use azithromycin 1 g alone for gonorrhea treatment 1
• Never use oral cephalosporins as first-line agents due to documented treatment failures 1
• Never delay treatment while awaiting chlamydia results if those results are unavailable 4
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 1