What is the recommended treatment for a patient diagnosed with gonorrhoea, considering potential co-infections and allergies to certain antibiotics?

Treatment of Gonorrhoea

The recommended first-line treatment for gonorrhoea is ceftriaxone 500 mg intramuscularly as a single dose plus azithromycin 1 g orally as a single dose, which treats both gonorrhoea and potential chlamydial co-infection. 1

Primary Treatment Regimen

Ceftriaxone 500 mg IM (single dose) + Azithromycin 1 g orally (single dose) is the standard of care for uncomplicated urogenital, anorectal, and pharyngeal gonorrhoea. 2, 1

Key Points About This Regimen:

• Ceftriaxone achieves 99.1% cure rates for uncomplicated urogenital and anorectal gonorrhoea 2
• The 500 mg dose represents an increase from older 250 mg recommendations due to antimicrobial stewardship concerns and evolving resistance patterns 1, 2
• Azithromycin is added for two critical reasons: (1) to cover potential chlamydial co-infection (present in 40-50% of gonorrhoea cases), and (2) to potentially delay emergence of cephalosporin resistance through dual-mechanism therapy 2, 3
• Azithromycin is strongly preferred over doxycycline due to single-dose convenience and substantially lower gonococcal resistance to azithromycin compared to tetracyclines 3, 2

Administration Details:

• Ceftriaxone must be injected deep intramuscularly into a large muscle mass with aspiration to avoid intravascular injection 4
• Both medications should be administered simultaneously at the initial visit 2
• No test-of-cure is required for patients treated with this recommended regimen unless symptoms persist 2, 5

Site-Specific Considerations

Pharyngeal Gonorrhoea:

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal infections 3, 2, 5
• Ceftriaxone is the ONLY reliably effective first-line agent for pharyngeal gonorrhoea, with 96% clearance rates 6, 5
• Alternative agents have unacceptably poor pharyngeal efficacy: spectinomycin (52%), gentamicin (20%) 2, 5
• Use the same regimen: ceftriaxone 500 mg IM + azithromycin 1 g orally 5

Genital and Rectal Sites:

• Clearance rates are excellent at both sites with standard therapy: 98% for genital, 98% for rectal 6
• Same dual therapy regimen applies to all anatomic sites 2

Alternative Regimens (When Ceftriaxone Unavailable)

If ceftriaxone is temporarily unavailable:

• Cefixime 400 mg orally (single dose) + Azithromycin 1 g orally (single dose) 3
• MANDATORY test-of-cure at 1 week is required with this regimen 3, 2
• This is inferior to ceftriaxone, particularly for pharyngeal infections, due to declining effectiveness from rising cefixime MICs 2

Severe Cephalosporin Allergy

For patients with documented severe cephalosporin allergy:

• Azithromycin 2 g orally as a single dose 3, 7
• MANDATORY test-of-cure at 1 week 7
• This regimen has lower efficacy (93%) and high gastrointestinal side effects 2, 8
• Consult an infectious disease specialist for guidance 7

Important Caveat:

• Azithromycin 1 g alone is NEVER adequate for gonorrhoea treatment (only 93% efficacy) 2, 5
• The 2 g dose is required when used as monotherapy 7

Special Populations

Pregnancy:

• Use the standard regimen: ceftriaxone 500 mg IM + azithromycin 1 g orally 2
• NEVER use quinolones or tetracyclines in pregnancy 3
• If cephalosporin allergy exists, use azithromycin 2 g orally with mandatory test-of-cure 7

Men Who Have Sex with Men (MSM):

• ONLY use ceftriaxone-based regimens due to higher prevalence of resistant strains 2
• NEVER use quinolones in this population 2
• Do NOT use expedited partner therapy in MSM due to high risk of undiagnosed co-existing STDs or HIV 2

Patients with Recent Foreign Travel:

• Ceftriaxone is the ONLY recommended treatment due to higher likelihood of resistant strains 2

Critical Pitfalls to Avoid

Obsolete Treatments - NEVER USE:

1. Quinolones (ciprofloxacin, ofloxacin) - widespread resistance makes these completely ineffective 3, 2, 1
2. Azithromycin 1 g as monotherapy - insufficient efficacy at 93% 2, 5
3. Spectinomycin for pharyngeal infections - only 52% effective 3, 2
4. Gentamicin for pharyngeal infections - only 20% effective 2, 6

Gentamicin Considerations:

• Gentamicin 240 mg IM + azithromycin 2 g orally showed 91% overall clearance in a 2019 RCT, failing to demonstrate non-inferiority to ceftriaxone 6
• Genital clearance was acceptable at 94%, but pharyngeal (80%) and rectal (90%) clearance were inadequate 6, 9
• Gentamicin causes significantly more injection site pain than ceftriaxone (mean pain score 36/100 vs 21/100) 6
• May be considered for isolated genital infection in patients with ceftriaxone allergy or intolerance, but NOT for pharyngeal or rectal infections 6, 2

Partner Management

All sexual partners from the preceding 60 days must be evaluated and treated: 3, 2

• Partners should receive the same dual therapy regimen (ceftriaxone + azithromycin) 2
• If partners cannot be linked to timely evaluation, consider expedited partner therapy with oral cefixime 400 mg + azithromycin 1 g 3, 2
• Patients must abstain from sexual intercourse until therapy is completed and both patient and partners are asymptomatic 3

Treatment Failure Management

If symptoms persist after recommended treatment: 2

1. Obtain specimens for culture immediately with antimicrobial susceptibility testing 3
2. Report the case to local public health officials within 24 hours 3, 2
3. Consult an infectious disease specialist 3, 7
4. Recommended salvage regimens include:
   • Gentamicin 240 mg IM + azithromycin 2 g orally (single dose) 2
   • Ertapenem 1 g IM for 3 days 2

Follow-Up and Testing

Routine Follow-Up:

• No test-of-cure needed for patients receiving ceftriaxone 500 mg + azithromycin 1 g unless symptoms persist 2, 5
• Consider retesting at 3 months due to high reinfection risk 2

Mandatory Test-of-Cure (at 1 week):

Required for patients receiving: 3, 2, 7

• Cefixime-based regimens
• Azithromycin 2 g monotherapy
• Any alternative regimen

Test-of-cure should ideally use culture to allow antimicrobial susceptibility testing; if culture unavailable, use NAAT 3, 7

Concurrent Testing Recommendations

At the time of gonorrhoea diagnosis: 2

• Screen for syphilis with serology
• Test for HIV (gonorrhoea facilitates HIV transmission)
• Test for chlamydia if not treating empirically