What are the recommended medications, including injections, for a couple diagnosed with gonorrhea and syphilis, considering potential penicillin allergy?

Treatment for Gonorrhea and Syphilis in a Couple

Gonorrhea Treatment

Both partners should receive dual therapy with ceftriaxone 250 mg intramuscularly PLUS azithromycin 1 g orally as a single dose, administered simultaneously under direct observation. 1, 2

• This dual therapy regimen is the only CDC-recommended first-line treatment for gonorrhea in the United States, as Neisseria gonorrhoeae has developed resistance to sulfonamides, tetracyclines, and penicillin. 1, 2
• Both medications must be given on the same day, preferably at the same time, to maximize efficacy and prevent resistance development. 1, 2
• Azithromycin is strongly preferred over doxycycline as the second agent because it provides single-dose directly observed therapy with 97% cure rates. 3
• Test-of-cure is not needed for uncomplicated urogenital or rectal gonorrhea when treated with this recommended regimen. 1, 2

Syphilis Treatment

For early syphilis (primary, secondary, or early latent <1 year duration), both partners should receive benzathine penicillin G 2.4 million units intramuscularly as a single dose. 4, 5

• This single intramuscular injection remains the gold standard treatment for syphilis, with decades of proven effectiveness. 4
• For late latent syphilis or syphilis of unknown duration, the regimen is benzathine penicillin G 2.4 million units intramuscularly weekly for three consecutive weeks (total 7.2 million units). 4
• Pregnant women must receive penicillin regardless of allergy status, requiring desensitization if necessary, as no alternative antibiotics are safe or effective during pregnancy. 4, 6

Management for Penicillin Allergy

For Syphilis in Nonpregnant Patients:

If either partner has a documented penicillin allergy, treat syphilis with doxycycline 100 mg orally twice daily for 14 days for early syphilis. 4, 6, 7

• Doxycycline is preferred over tetracycline due to better compliance, though tetracycline 500 mg orally four times daily for 14 days is an acceptable alternative. 4, 6
• For late latent syphilis or syphilis of unknown duration in penicillin-allergic patients, extend doxycycline to 100 mg orally twice daily for 28 days. 6, 7
• If compliance cannot be ensured, penicillin desensitization is strongly recommended over alternative antibiotics. 4, 6

For Gonorrhea in Severe Penicillin Allergy:

Ceftriaxone can still be used for gonorrhea in most penicillin-allergic patients, but is contraindicated in those with documented IgE-mediated anaphylaxis to penicillin. 3

• For patients with severe IgE-mediated penicillin reactions, spectinomycin 2 g intramuscularly as a single dose is the recommended alternative, with 98.2% cure rates. 3
• If spectinomycin is unavailable (which is common), ciprofloxacin 500 mg orally as a single dose may be used if local resistance patterns permit and the patient is not a man who has sex with men, has not traveled recently, and the infection was not acquired in areas with known quinolone resistance. 3

Critical Follow-Up Requirements

Both partners must abstain from sexual intercourse for 7 days after completing single-dose therapy or until completion of multi-day regimens. 3

• For syphilis, quantitative nontreponemal serologic tests (RPR or VDRL) should be repeated at 6 and 12 months after treatment. 4
• Treatment failure for syphilis is indicated by failure of nontreponemal titers to decline fourfold within 6 months, requiring re-treatment with three weekly injections of benzathine penicillin G 2.4 million units intramuscularly. 4
• For gonorrhea, retesting at 3 months is recommended due to high reinfection rates (9.9% within 2 years), with most infections representing reinfection rather than treatment failure. 1, 8
• HIV testing should be performed for all patients diagnosed with syphilis or gonorrhea. 4

Common Pitfalls to Avoid

• Never use azithromycin 2 g alone for gonorrhea—it causes significant gastrointestinal distress and has insufficient efficacy at 93%. 3
• Never assume spectinomycin works for pharyngeal gonorrhea—efficacy is only 52% at this site. 3
• Never use erythromycin for gonorrhea—N. gonorrhoeae in the United States is not adequately susceptible. 3
• Never use single-dose ceftriaxone for syphilis—it is not effective and requires 8-10 days of treponemicidal levels. 4
• Approximately 90% of patients reporting penicillin allergy are no longer allergic, so consider penicillin skin testing when available to avoid unnecessary use of less effective alternatives. 3