Recheck Following Gonorrhea Treatment
Patients treated with the recommended first-line regimen (ceftriaxone plus azithromycin) do NOT need a test-of-cure visit, but ALL patients should return for reinfection screening at 3 months after treatment. 1, 2
Test-of-Cure: Not Routinely Required
For standard therapy, skip the test-of-cure. Patients with uncomplicated gonorrhea who receive the recommended combination therapy (ceftriaxone 250-500 mg IM plus azithromycin 1 g orally) do not require a test-of-cure visit. 1, 2
When Test-of-Cure IS Mandatory
Test-of-cure at 1 week after treatment is required in these specific circumstances:
Alternative regimens used: Patients treated with cefixime (instead of ceftriaxone) or azithromycin monotherapy must return in 1 week for test-of-cure at the infected anatomic site. 1, 3
Severe cephalosporin allergy: Patients receiving azithromycin 2 g as monotherapy require mandatory test-of-cure at 1 week. 1, 3
Persistent symptoms: Any patient with ongoing symptoms after treatment should undergo culture with antimicrobial susceptibility testing immediately. 1, 3, 2
Pharyngeal infections treated with spectinomycin: This agent has only 52% efficacy for pharyngeal gonorrhea, necessitating test-of-cure 3-5 days after treatment. 1, 3
How to Perform Test-of-Cure
Preferred method: Culture at the infected anatomic site with antimicrobial susceptibility testing if positive. 1
Alternative: NAAT if culture is not readily available, but any positive NAAT must be confirmed with culture and susceptibility testing. 1, 3
Reinfection Screening: Required for ALL Patients
The critical visit is at 3 months, not immediately after treatment. This addresses reinfection, not treatment failure. 1, 2
Why 3-Month Retesting Matters
High reinfection rates: Patients with gonorrhea face substantially elevated risk of acquiring a new infection in subsequent months, with most post-treatment infections representing reinfection rather than treatment failure. 1, 2
Inadequate partner treatment: The majority of reinfections indicate inadequate partner treatment or new exposures, even when patients report their partners were treated. 1, 2
Distinct from test-of-cure: This 3-month screening detects new infections, not treatment failures. 1, 2
Implementation Strategy
Primary approach: Schedule all patients for retesting 3 months after treatment, regardless of whether they believe their sex partners were treated. 1, 2
Opportunistic testing: If patients don't return at 3 months, test whenever they next seek care within 12 months. 2
Comprehensive screening: At the 3-month visit, also test for chlamydia, syphilis, and HIV given the high rates of co-infection and facilitation of HIV transmission by gonorrhea. 3, 2
Special Populations Requiring Enhanced Follow-Up
Pregnant Women
First trimester diagnosis: Retest 3 months after treatment. 2
Second trimester diagnosis: Retest in the third trimester unless recently treated. 2
Treatment Failure Cases
If treatment failure is suspected (persistent symptoms or positive test-of-cure):
Immediate actions: Obtain culture with antimicrobial susceptibility testing, report to local health department within 24 hours, and consult infectious disease specialist. 1, 3
Salvage regimens: Options include gentamicin 240 mg IM plus azithromycin 2 g orally, or ertapenem 1 g IM for 3 days. 3
Common Pitfalls to Avoid
Don't confuse test-of-cure with reinfection screening: Test-of-cure (1 week) detects treatment failure; 3-month retesting detects reinfection. These serve different purposes. 2
Don't skip retesting based on partner treatment status: High reinfection rates occur even when patients report partner treatment, making universal 3-month screening essential. 1, 2
Don't order routine test-of-cure for standard therapy: This wastes resources and is not recommended for patients receiving ceftriaxone plus azithromycin. 1, 2
Don't forget partner management: All sex partners from the preceding 60 days should be evaluated and treated, as inadequate partner treatment drives most reinfections. 1, 3