What is the recommended treatment for a patient diagnosed with gonorrhea versus chlamydia?

Treatment for Gonorrhea versus Chlamydia

For gonorrhea, use ceftriaxone 500 mg IM plus azithromycin 1 g orally as a single dose; for chlamydia alone, use either azithromycin 1 g orally as a single dose OR doxycycline 100 mg orally twice daily for 7 days. 1, 2

Gonorrhea Treatment

Primary Recommended Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the only first-line treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx 1, 3, 4
• This dual therapy addresses both gonorrhea and presumptive chlamydial co-infection, which occurs in 40-50% of gonorrhea cases 1, 2
• The 500 mg dose (increased from previous 250 mg recommendations) is particularly critical for pharyngeal infections due to variable cephalosporin penetration into tonsillar tissue 1

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 due to inferior efficacy compared to ceftriaxone 1, 2
  • Cefixime has declining effectiveness with cure rates of only 95.9% for urogenital infections 6

• For severe cephalosporin allergy: Azithromycin 2 g orally (single dose) 1, 7

  • Requires mandatory test-of-cure at 1 week 1
  • Causes gastrointestinal side effects in 35% of patients (moderate in 10%, severe in 3%) 7
  • Has lower efficacy (93-99%) compared to ceftriaxone 1, 7

• Gentamicin 240 mg IM PLUS azithromycin 2 g orally is an alternative with 100% cure rate in clinical trials 1, 8

  • However, gentamicin has poor pharyngeal efficacy (only 20% cure rate) 1

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 1, 2
• Ceftriaxone has superior pharyngeal efficacy compared to all oral alternatives 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided if pharyngeal exposure is suspected 1, 2

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea due to widespread resistance 6, 1, 2
• Never use azithromycin 1 g alone for gonorrhea treatment - it has only 93% efficacy and risks rapid resistance emergence 6, 1, 2
• Never use penicillins, tetracyclines, or macrolides (erythromycin) alone - N. gonorrhoeae in the United States is not adequately susceptible 6

Chlamydia Treatment

Primary Recommended Regimens

• Azithromycin 1 g orally (single dose) 1, 2, 9

  • Preferred for single-dose convenience and compliance 1

• Doxycycline 100 mg orally twice daily for 7 days 2, 10, 3

  • Alternative to azithromycin when single-dose therapy is not feasible 2
  • Required when azithromycin cannot be used 2

Key Distinction

• Unlike gonorrhea, chlamydia can be treated with azithromycin 1 g as monotherapy 9
• Chlamydia does not require dual therapy unless gonorrhea co-infection is suspected 1, 2

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) for gonorrhea 1, 2, 4
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 1, 2, 10
• For chlamydia alone in pregnancy: azithromycin 1 g orally or amoxicillin 500 mg three times daily for 7 days 10

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 MSM 6, 1
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Patients with Recent Foreign Travel

• Use ceftriaxone (not quinolones or oral alternatives) due to increased prevalence of resistant strains 6, 1

Follow-Up Requirements

Test-of-Cure

• NOT needed for patients treated with recommended ceftriaxone plus azithromycin regimen unless symptoms persist 1, 2
• Mandatory test-of-cure at 1 week for patients receiving cefixime or azithromycin monotherapy 1, 2
• If symptoms persist, obtain culture with antimicrobial susceptibility testing 6, 1

Retesting for Reinfection

• All patients should be retested approximately 3 months after treatment due to high reinfection rates 6, 1, 2
• Most post-treatment infections result from reinfection rather than treatment failure 6
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester 4

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia with the same dual therapy regimen 6, 1, 2
• 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 when partners cannot be linked to timely evaluation 1
  • Not recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately 1
• Report the case to local public health officials within 24 hours 1
• Consult an infectious disease specialist 1
• Recommended salvage regimens include:
  • Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1
  • Ertapenem 1 g IM for 3 days 1

Additional Screening Considerations

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1
• Co-test for HIV given that gonorrhea facilitates HIV transmission 1, 3
• All patients with sexually-transmitted urethritis or cervicitis should have appropriate cultures for gonorrhea performed at diagnosis 6