Treatment for Suspected Gonorrhea
Treat with ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days to cover presumptive chlamydial coinfection. 1, 2
Primary Treatment Regimen
The CDC updated its gonorrhea treatment guidelines in 2020, increasing the ceftriaxone dose from 250 mg to 500 mg due to antimicrobial stewardship concerns and rising azithromycin resistance. 2 This regimen achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea, and 100% cure rate for pharyngeal infections. 3, 1
Key components of the recommended regimen:
- Ceftriaxone 500 mg IM single dose - The higher dose is particularly critical for pharyngeal infections where cephalosporins have variable tissue penetration. 3, 1
- Doxycycline 100 mg orally twice daily for 7 days - This replaces the previous azithromycin 1 g single dose recommendation, addressing the 40-50% coinfection rate with chlamydia while reducing selective pressure for azithromycin resistance. 1, 2
Alternative Regimens (When Ceftriaxone Unavailable)
If ceftriaxone cannot be administered:
- Use cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose. 3, 1
- Mandatory test-of-cure at 1 week is required with this regimen due to lower efficacy and documented treatment failures in Europe. 3, 1
Severe Cephalosporin Allergy
For patients with documented severe cephalosporin allergy:
- Azithromycin 2 g orally single dose is the alternative, though it has only 93% efficacy and causes significant gastrointestinal side effects. 3, 1, 4
- Mandatory test-of-cure at 1 week is required. 3, 1
- Gentamicin 240 mg IM plus azithromycin 2 g orally achieved 100% cure in clinical trials for urogenital infections, but has poor pharyngeal efficacy (only 20% cure rate). 3, 5, 6
Special Populations
Pregnant women:
- Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally (single dose). 1, 7
- Never use quinolones, tetracyclines, or doxycycline in pregnancy. 3, 1
Men who have sex with men (MSM):
- Ceftriaxone-based regimens are mandatory due to higher prevalence of resistant strains. 3, 1
- Never use quinolones in this population. 3, 1
Critical Pitfalls to Avoid
Never use the following:
- Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) - Widespread resistance makes these completely ineffective despite historical 99.8% cure rates. 3, 1
- Azithromycin 1 g alone - Only 93% efficacy, insufficient as monotherapy. 3, 1
- Spectinomycin for pharyngeal infections - Only 52% effective at this site. 3, 1
Follow-Up Requirements
Patients treated with first-line ceftriaxone 500 mg regimen:
- Do NOT need routine test-of-cure unless symptoms persist. 3, 1
- Consider retesting at 3 months due to high reinfection risk (most post-treatment infections are reinfection, not treatment failure). 1, 7
Mandatory test-of-cure at 1 week required for:
If symptoms persist after treatment:
- Obtain culture with antimicrobial susceptibility testing immediately. 3, 1
- Report suspected treatment failure to local public health officials within 24 hours. 3
- Consult infectious disease specialist. 3
Partner Management
All sexual partners from the preceding 60 days must be evaluated and treated:
- Treat partners with the same dual therapy regimen for both gonorrhea and chlamydia. 3, 1
- Consider expedited partner therapy (EPT) with oral cefixime 400 mg plus azithromycin 1 g if partners cannot access timely evaluation. 1, 7
- Do NOT use EPT for MSM due to high risk of undiagnosed coexisting STDs or HIV. 1, 7
- Patients should abstain from sexual intercourse until therapy is completed and both partners are asymptomatic. 3
Concurrent Testing Requirements
At the time of gonorrhea diagnosis, always:
- Screen for syphilis with serology. 3, 1
- Perform HIV testing (gonorrhea facilitates HIV transmission). 3, 1
- Test for chlamydia if not treating presumptively. 1, 7
Site-Specific Considerations
Pharyngeal gonorrhea is significantly more difficult to eradicate: