What is the recommended treatment for gonorrhea?

Treatment for Gonorrhea

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose, plus concurrent treatment for chlamydia with either azithromycin 1 g orally once OR doxycycline 100 mg orally twice daily for 7 days if chlamydial co-infection has not been excluded. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the cornerstone of gonorrhea treatment, achieving a 99.1% cure rate for uncomplicated urogenital and anorectal infections 1, 3
• Add azithromycin 1 g orally once OR doxycycline 100 mg orally twice daily for 7 days to cover presumptive chlamydial co-infection, as 40-50% of gonorrhea patients have concurrent chlamydia 1, 2
• The shift from azithromycin to doxycycline as the preferred chlamydia coverage reflects antimicrobial stewardship concerns and rising azithromycin resistance 2
• This regimen effectively treats gonorrhea at cervical, urethral, rectal, and pharyngeal sites 1

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is not available:

• Use cefixime 400 mg orally once PLUS azithromycin 1 g orally once 1, 4
• Critical caveat: Cefixime is significantly less effective than ceftriaxone, particularly for pharyngeal infections 4
• Mandatory test-of-cure at 1 week is required with this regimen 1, 4

For severe cephalosporin allergy:

• Azithromycin 2 g orally once is an option, but has only 93% efficacy and high gastrointestinal side effects 1, 4
• Requires mandatory test-of-cure at 1 week 1, 4
• Gentamicin 240 mg IM plus azithromycin 2 g orally achieved 100% cure rate in clinical trials, but has poor pharyngeal efficacy (only 20% cure rate) 1, 5, 6

Site-Specific Considerations

Pharyngeal gonorrhea requires special attention:

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal infections 1
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal gonorrhea 1
• Gentamicin showed only 80% clearance for pharyngeal infections compared to 96% with ceftriaxone 5
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided 1

Special Populations

Pregnant women:

• Use ceftriaxone 500 mg IM plus azithromycin 1 g orally 1, 4
• Never use quinolones or tetracyclines in pregnancy 1, 4
• Doxycycline is absolutely contraindicated 1

Men who have sex with men (MSM):

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 1, 4
• Never use quinolones in this population 1, 4
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 1

Neonates:

• Administer IV doses over 60 minutes to reduce risk of bilirubin encephalopathy 7
• Ceftriaxone is contraindicated in premature neonates and neonates ≤28 days requiring calcium-containing IV solutions 7

Critical Pitfalls to Avoid

Never use the following:

• Fluoroquinolones (ciprofloxacin, ofloxacin) - widespread resistance makes them obsolete despite historical 99.8% cure rates 1
• Azithromycin 1 g alone - insufficient efficacy at only 93% 1
• Oral cephalosporins as first-line - documented treatment failures in Europe 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen 1, 3, 4
• If the last sexual contact was >60 days before diagnosis, treat the most recent partner 4
• Consider expedited partner therapy with oral cefixime 400 mg plus azithromycin 1 g if partners cannot be linked to timely evaluation 1, 3
• Exception: Do not use expedited partner therapy for MSM 1
• Patients should avoid sexual intercourse until therapy is completed and both partners are asymptomatic 1

Follow-Up and Testing Requirements

Routine follow-up:

• Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist 1
• Consider retesting all patients 3 months after treatment due to high risk of reinfection 1, 3

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

• Patients receiving cefixime-based regimens 1, 4
• Patients receiving azithromycin monotherapy 1
• Patients with severe cephalosporin allergy receiving alternative regimens 1

Concurrent testing:

• Screen for syphilis with serology at time of gonorrhea diagnosis 1, 4
• Perform HIV testing given facilitation of HIV transmission by gonorrhea 1

Treatment Failure Management

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 3
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1

Salvage regimens for ceftriaxone treatment failure:

• Gentamicin 240 mg IM plus azithromycin 2 g orally (single dose) 1
• Ertapenem 1 g IM for 3 days 1
• Most treatment failures involve pharyngeal sites, not urogenital 1

Administration Details

Ceftriaxone preparation and administration:

• For IM injection: Reconstitute 500 mg vial with 1.0 mL diluent to achieve 350 mg/mL concentration 7
• Inject well within the body of a relatively large muscle 7
• Do not use diluents containing calcium (Ringer's solution, Hartmann's solution) as precipitation can occur 7
• For IV administration in hospitalized patients: Administer over 30 minutes (60 minutes in neonates) 7