What is the recommended treatment for a patient with recurrent gonorrhea, considering the risk of antibiotic-resistant strains and potential co-transmission of other sexually transmitted infections?

Recurrent Gonorrhea Treatment

For recurrent gonorrhea, treat with ceftriaxone 500 mg IM plus azithromycin 1 g orally as a single dose, obtain culture with antimicrobial susceptibility testing, evaluate and treat all sexual partners from the preceding 60 days, and retest the patient 3 months after treatment due to high reinfection risk. 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) is the recommended dual therapy for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 1, 2
• The 500 mg ceftriaxone dose (increased from the previous 250 mg recommendation) provides superior efficacy, particularly for pharyngeal infections where extended-spectrum cephalosporins have marked variability in tissue penetration 1
• Dual therapy addresses both rising antibiotic resistance patterns and potential chlamydial co-infection, which occurs in 40-50% of gonorrhea cases 1

Critical Evaluation for Recurrent Infection

Distinguish between treatment failure versus reinfection:

• Obtain culture with antimicrobial susceptibility testing immediately if symptoms persist or recur after treatment 1
• Report suspected treatment failures to local public health officials within 24 hours 1
• Consult an infectious disease specialist for confirmed treatment failures 1
• Most "recurrent" cases represent reinfection from untreated partners rather than true treatment failure 3

Management of Confirmed Treatment Failure

If antimicrobial resistance is documented, use salvage regimens:

• Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1
• Alternative: Ertapenem 1 g IM for 3 days 1
• Note: Both spectinomycin and gentamicin have poor pharyngeal efficacy (52% and 20% cure rates respectively), so avoid these for pharyngeal infections 1

Partner Management and Reinfection Prevention

Comprehensive partner evaluation is essential:

• Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen 1
• Patients must avoid sexual intercourse until both they and their partners complete therapy and are asymptomatic 1
• Consider expedited partner therapy (providing medication directly to partners) if partners cannot be linked to timely evaluation, using oral cefixime 400 mg plus azithromycin 1 g 1
• Exception: Do not use expedited partner therapy for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV 1

Mandatory Follow-Up

• Retest all patients 3 months after treatment due to high reinfection rates (not as a test-of-cure) 1
• If nucleic acid amplification testing is positive at follow-up, confirm with culture and perform antimicrobial susceptibility testing 1
• Patients treated with recommended ceftriaxone-based regimens do not require routine test-of-cure unless symptoms persist 1

Antimicrobial Resistance Considerations

Critical pitfalls to avoid:

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite their historical 99.8% cure rates 1, 3
• Never use azithromycin 1 g alone for gonorrhea treatment (only 93% efficacy) 1
• Cefixime 400 mg orally plus azithromycin 1 g is an alternative only when ceftriaxone is unavailable, but requires mandatory test-of-cure at 1 week 1
• Rising azithromycin resistance (increased from 0.6% in 2013 to 2.5% in 2014) underscores the importance of ceftriaxone as the primary agent 4

Special Population Considerations

Men who have sex with men (MSM):

• Use only ceftriaxone-based regimens due to higher prevalence of resistant strains 1
• Do not use quinolones or patient-delivered partner therapy 1

Pregnant women:

• Use ceftriaxone 500 mg IM plus azithromycin 1 g orally 1
• Avoid quinolones and tetracyclines (doxycycline) 1, 5

Patients with severe cephalosporin allergy:

• Azithromycin 2 g orally (single dose) with mandatory test-of-cure at 1 week 1
• This regimen has lower efficacy (93%) and high gastrointestinal side effects 1

Concurrent STI Screening

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1
• Perform HIV testing given gonorrhea's facilitation of HIV transmission 1, 2
• Test for chlamydia if not already treating presumptively 1