Recommended Antibiotic Course for Gonorrhea and Chlamydia
The recommended treatment is ceftriaxone 500 mg IM as a single dose PLUS azithromycin 1 g orally as a single dose for empiric coverage of both gonorrhea and chlamydia. 1, 2
Primary Treatment Regimen
- Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) is the first-line dual therapy for uncomplicated gonorrhea with presumptive chlamydia coverage. 1, 2
- This regimen provides true single-dose therapy for both infections, maximizing compliance and treatment success. 1
- Co-infection rates are extremely high (40-50% of gonorrhea patients also have chlamydia), making dual therapy essential even without confirmed chlamydia testing. 1
Alternative Chlamydia Coverage
- If azithromycin cannot be used or chlamydial infection has not been excluded, doxycycline 100 mg orally twice daily for 7 days is the alternative for chlamydia coverage. 1, 3, 4
- This is NOT a single-dose regimen and requires 7 days of treatment. 1, 3
- Doxycycline should be taken with adequate fluids to reduce risk of esophageal irritation. 3
Alternative Regimens When Ceftriaxone Unavailable
- Cefixime 400 mg orally (single dose) PLUS azithromycin 1 g orally (single dose) can be used if ceftriaxone is unavailable. 1, 5
- Mandatory test-of-cure at 1 week is required with this regimen due to inferior efficacy compared to ceftriaxone. 1, 5
Critical Site-Specific Considerations
- Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 1, 5
- Ceftriaxone has superior efficacy for pharyngeal infections compared to all oral alternatives. 1, 5
- Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected. 1, 2
Critical Pitfalls to Avoid
- Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance. 1, 2, 5
- Never use azithromycin 1 g alone for gonorrhea treatment—it has only 93% efficacy. 1, 5
- Never use doxycycline, quinolones, or tetracyclines in pregnancy. 1, 5
Special Populations
Pregnancy
- Use ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose). 1, 5, 6
- Doxycycline is absolutely contraindicated in pregnancy. 1, 3
Men Who Have Sex with Men (MSM)
- Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains. 5
- Never use quinolones in this population. 5
Follow-Up Requirements
- Patients treated with the recommended ceftriaxone plus azithromycin regimen do NOT need routine test-of-cure unless symptoms persist. 1, 6
- All patients should be retested approximately 3 months after treatment due to high reinfection risk. 1, 2, 6
- If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing. 5
Partner Management
- All sexual partners from the preceding 60 days should be evaluated and treated with the same dual therapy regimen. 1, 2, 5
- Patients should avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 1, 2
- Expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) may be considered if partners cannot be linked to timely evaluation, but this is NOT recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV. 5
Administration Considerations
- Dual therapy should be administered together on the same day, preferably simultaneously, and under direct observation when possible. 1, 6
- Medications should be dispensed on-site when possible, with the first dose directly observed to maximize compliance. 2
- Patients should abstain from sexual activity for 7 days after single-dose therapy. 2