What is the recommended first-line treatment for a patient diagnosed with gonorrhea and chlamydia?

Gonorrhea and Chlamydia Treatment

First-Line Treatment Recommendation

For patients diagnosed with both gonorrhea and chlamydia (or when co-infection cannot be excluded), administer ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1

This represents the most current CDC guidance from 2020, which moved away from routine azithromycin dual therapy due to antimicrobial stewardship concerns and rising azithromycin resistance. 1

Treatment Algorithm

When Chlamydia Co-Infection is Confirmed or Suspected:

• Ceftriaxone 500 mg IM (single dose) for gonorrhea 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days for chlamydia 1
• This regimen achieves 99.1% cure rate for gonorrhea and 98% cure rate for chlamydia 2, 3

Alternative Regimen (When Compliance is Questionable):

• Ceftriaxone 500 mg IM (single dose) PLUS Azithromycin 1 g orally (single dose) 3, 4
• Single-dose azithromycin ensures directly observed therapy and eliminates compliance concerns with 7-day doxycycline 2
• This remains appropriate when adherence to multi-day regimens is uncertain 2

When Ceftriaxone is Unavailable:

• Cefixime 400 mg orally (single dose) PLUS Azithromycin 1 g orally (single dose) 3, 5
• Mandatory test-of-cure at 1 week required due to lower cure rate (95.9%) 3, 5

Rationale for Current Recommendations

Why Dual Therapy is Essential:

• Co-infection rates are 10-50% depending on population, making presumptive treatment cost-effective 3, 6
• The cost of chlamydia therapy is less than the cost of testing 6
• Dual therapy addresses antimicrobial resistance concerns and prevents treatment failures 4, 1

Why Ceftriaxone Dose Increased:

• Previous 250 mg dose is no longer optimal due to evolving resistance patterns 6, 1
• 500 mg dose is particularly critical for pharyngeal infections, which are more difficult to eradicate 3, 5
• Ceftriaxone achieves 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 3

Why Doxycycline is Now Preferred Over Azithromycin:

• Rising azithromycin resistance in gonorrhea prompted the 2020 guideline change 1
• Antimicrobial stewardship concerns about azithromycin's impact on commensal organisms 1
• Doxycycline costs less than azithromycin with equivalent efficacy for chlamydia 2

Special Populations

Pregnant Women:

• Ceftriaxone 500 mg IM (single dose) PLUS Azithromycin 1 g orally (single dose) 3, 4
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 3, 5
• Alternative for chlamydia: Amoxicillin 500 mg three times daily for 7 days 3
• Retest in third trimester unless recently treated 4

Men Who Have Sex with Men (MSM):

• Ceftriaxone is the only recommended treatment due to higher prevalence of resistant strains 3, 5
• Never use quinolones in this population 3, 5
• Do not use patient-delivered partner therapy due to high risk of undiagnosed coexisting STDs or HIV 3, 5

Severe Cephalosporin Allergy:

• Azithromycin 2 g orally (single dose) with mandatory test-of-cure at 1 week 5
• Lower efficacy (93%) and high gastrointestinal side effects 5
• Alternative: Gentamicin 240 mg IM PLUS Azithromycin 2 g orally (100% cure rate in trials) 5

Critical Pitfalls to Avoid

Never Use These Agents:

• Fluoroquinolones (ciprofloxacin, ofloxacin) - widespread resistance despite historical 99.8% cure rates 6, 5
• Azithromycin 1 g alone for gonorrhea - only 93% efficacy, insufficient as monotherapy 5
• Spectinomycin for pharyngeal infections - only 52% effective 6, 5

Common Errors:

• Failing to treat pharyngeal gonorrhea adequately - requires ceftriaxone, not oral alternatives 5
• Using lower ceftriaxone doses (125-250 mg) - no longer optimal 6, 1
• Neglecting partner treatment - leads to reinfection rather than treatment failure 6, 5

Follow-Up Requirements

Routine Follow-Up:

• No test-of-cure needed for patients treated with recommended regimens unless symptoms persist 4, 1
• Retest approximately 3 months after treatment due to high reinfection rates (especially in women and adolescents) 2, 3, 4
• Patients should abstain from sexual activity for 7 days after single-dose therapy or until completion of 7-day regimen 2, 6

Mandatory Test-of-Cure Required For:

• Patients receiving cefixime or azithromycin monotherapy (at 1 week) 3, 5
• Patients with severe cephalosporin allergy receiving alternative regimens 5
• Pregnant women (retest in third trimester) 4

Treatment Failure Management:

• Obtain culture with antimicrobial susceptibility testing immediately 3, 5
• Report to local public health officials within 24 hours 3, 5
• Consult infectious disease specialist 3, 5
• Salvage regimens: Gentamicin 240 mg IM PLUS Azithromycin 2 g orally, or Ertapenem 1 g IM for 3 days 5

Partner Management

All Sexual Partners from Preceding 60 Days Must:

• Be evaluated and treated with the same dual therapy regimen 3, 5
• Receive treatment for both gonorrhea and chlamydia regardless of testing 3, 5
• Avoid sexual intercourse until therapy completed and both patient and partners are asymptomatic 2, 5

Expedited Partner Therapy:

• Consider oral combination therapy (cefixime 400 mg plus azithromycin 1 g) when partners cannot be linked to timely evaluation 5
• Not recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV 3, 5

Additional Screening Considerations

Concurrent Testing Recommended:

• Screen for syphilis with serology at time of gonorrhea diagnosis 3, 5
• Co-test for HIV given that gonorrhea facilitates HIV transmission 3, 5

Medication Administration:

• Dispense medications on-site when possible 2, 6
• First dose should be directly observed to maximize compliance 2, 6
• Dual therapy should be administered on the same day, preferably simultaneously 4