What is the recommended treatment regimen for a patient with recurrent gonorrhoea?

Recurrent Gonorrhoea Treatment

For recurrent gonorrhoea, treat with ceftriaxone 500 mg IM plus azithromycin 1 g orally as a single dose, obtain culture with antimicrobial susceptibility testing, and report to public health authorities within 24 hours. 1

Initial Management of Recurrent Infection

Recurrent gonorrhoea most commonly represents reinfection rather than treatment failure, particularly if the patient was treated with a recommended regimen initially. 2 However, true treatment failure must be ruled out through proper testing and evaluation.

Immediate Actions Required

• Obtain specimens for culture and antimicrobial susceptibility testing immediately before initiating treatment—this is critical for detecting resistant strains. 1
• Report the case to local public health officials within 24 hours if treatment failure is suspected. 1
• Consult an infectious disease specialist for guidance on management. 1

Recommended Treatment Regimen

First-Line Therapy

• Ceftriaxone 500 mg IM plus azithromycin 1 g orally as a single dose remains the optimal treatment for recurrent gonorrhoea. 1, 3
• This dual therapy achieves 99.1% cure rates for uncomplicated urogenital and anorectal gonorrhoea. 1
• The combination addresses both potential antimicrobial resistance and concurrent chlamydial infection (present in 40-50% of gonorrhoea cases). 1

Alternative Regimens (If Ceftriaxone Unavailable)

• Cefixime 400 mg orally plus azithromycin 1 g orally as a single dose, but this requires mandatory test-of-cure at 1 week due to lower efficacy, particularly for pharyngeal infections. 1, 4
• Cefixime is less effective than ceftriaxone and should only be used when ceftriaxone is truly unavailable. 5

For Severe Cephalosporin Allergy

• Azithromycin 2 g orally as a single dose with mandatory test-of-cure at 1 week. 1
• This regimen has lower efficacy (93%) and high gastrointestinal side effects (35.3% of patients experience GI symptoms). 1, 6
• Gentamicin 240 mg IM plus azithromycin 2 g orally is an alternative with 100% cure rate in clinical trials. 1, 7

Salvage Regimens for Confirmed Treatment Failure

If culture confirms persistent infection after appropriate treatment:

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

Critical caveat: Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for pharyngeal gonorrhoea. 1 Gentamicin also has poor pharyngeal efficacy (only 20% cure rate). 1

Site-Specific Considerations

• Pharyngeal gonorrhoea is significantly more difficult to eradicate than urogenital or anorectal infections. 1
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections—oral alternatives have substantially lower cure rates. 1
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites. 1

Critical Follow-Up Requirements

• Mandatory test-of-cure at 1 week is required for patients receiving cefixime-based regimens or azithromycin monotherapy. 1
• Retest all patients 3 months after treatment due to high risk of reinfection (not treatment failure). 1, 8
• If nucleic acid amplification testing is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing. 1

Partner Management

• Evaluate and treat all sex partners from the preceding 60 days with the same dual therapy regimen for both gonorrhoea and chlamydia. 1, 5
• If partners cannot be linked to timely evaluation, consider expedited partner therapy with oral cefixime 400 mg plus azithromycin 1 g. 1
• 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
• Patients should avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic. 2, 1

Special Population Considerations

Pregnant Women

• Use ceftriaxone (preferred cephalosporin) plus azithromycin 1 g orally. 1, 8
• Never use quinolones or tetracyclines in pregnancy. 2, 1
• If ceftriaxone cannot be used, spectinomycin 2 g IM is an alternative. 2

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 due to widespread resistance. 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhoea treatment due to widespread resistance, despite their historical 99.8% cure rates. 1, 3
• Never use azithromycin 1 g alone for gonorrhoea treatment—it has insufficient efficacy (only 93% cure rate). 1
• Never substitute oral cephalosporins for ceftriaxone when treating pharyngeal infections—they have substantially lower efficacy. 1
• Do not skip culture and susceptibility testing in recurrent cases—this is essential for detecting emerging resistance patterns. 1

Concurrent Testing Requirements

• Screen for syphilis with serology at the time of gonorrhoea diagnosis. 5
• Perform HIV testing given that gonorrhoea facilitates HIV transmission. 1
• Test for chlamydia and treat presumptively if testing is not immediately available. 1, 3