What is the recommended antibiotic dosing regimen for a pregnant woman with gonorrhea, considering her past medical history and potential allergies?

Drug Dosing for Pregnant Women with Gonorrhea

Pregnant women with gonorrhea should be treated with ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, administered together on the same day under direct observation. 1, 2

Primary Treatment Regimen

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g orally single dose is the only recommended first-line regimen for gonorrhea in pregnancy. 1, 2
• Both medications should be administered simultaneously on the same day, preferably under direct observation to ensure compliance. 1, 2
• This dual therapy achieves a 95% cure rate for gonococcal infections in pregnancy and addresses the 40-50% co-infection rate with chlamydia. 3, 4

Rationale for Dual Therapy

• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are absolutely contraindicated in pregnancy due to potential fetal harm. 5, 6
• Tetracyclines (doxycycline) are absolutely contraindicated in pregnancy. 5, 6
• Single-agent azithromycin has only 93% efficacy for gonorrhea and should never be used as monotherapy. 3
• Dual therapy with different mechanisms of action helps prevent antimicrobial resistance development. 3

Alternative Regimens for Cephalosporin Allergy

• If the patient cannot tolerate ceftriaxone, spectinomycin 2 g IM single dose is the alternative, though it is no longer widely available. 5
• Spectinomycin achieves 95% cure rates for urogenital and rectal gonorrhea in pregnancy. 4
• Critical pitfall: Spectinomycin is only 52% effective against pharyngeal gonorrhea, so patients with pharyngeal infection require pharyngeal culture follow-up 3-5 days after treatment. 5

Treatment for Concurrent Chlamydia

• Because 40% of pregnant women with gonorrhea have concurrent chlamydia, the azithromycin component of dual therapy addresses both infections. 3, 4
• If azithromycin cannot be used, alternative chlamydia treatment in pregnancy includes amoxicillin 500 mg orally three times daily for 7 days or erythromycin base 500 mg orally four times daily for 7 days. 5
• Never use erythromycin estolate in pregnancy due to drug-related hepatotoxicity. 7

Regimens to Avoid in Pregnancy

• Amoxicillin 3 g orally plus probenecid 1 g orally has only 89% efficacy and is NOT recommended for gonorrhea in pregnancy. 4
• All fluoroquinolones are absolutely contraindicated. 5, 6
• All tetracyclines are absolutely contraindicated. 5, 6

Follow-Up Requirements

• Test-of-cure is NOT needed for pregnant women treated with the recommended dual therapy regimen (ceftriaxone plus azithromycin). 1, 2
• All pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated, due to high reinfection rates. 1, 2
• Retest at 3 months after treatment to screen for reinfection, which occurs frequently and increases risks of preterm delivery and other complications. 1, 2

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen. 3
• Partners should receive treatment even if asymptomatic, as untreated partners lead to reinfection in up to 20% of cases. 7
• Patients must abstain from sexual intercourse until therapy is completed and both partners are treated. 5

Site-Specific Considerations

• For pharyngeal gonorrhea in pregnancy, ceftriaxone is the only reliably effective treatment, as spectinomycin has only 52% efficacy at this site. 5, 3
• Rectal gonorrhea occurs in 27% of pregnant women with gonorrhea and responds equally well to ceftriaxone. 4

Safety Profile

• Ceftriaxone has an excellent safety record in pregnancy with no increased incidence of congenital malformations. 4
• Hyperbilirubinemia may be more frequent in neonates exposed to ceftriaxone, though this is generally clinically insignificant. 8
• Injection site pain is common with intramuscular ceftriaxone but is not quantified in most studies. 8

Critical Clinical Pitfalls

• Never delay treatment waiting for culture results if compliance with follow-up is uncertain—treat presumptively based on clinical diagnosis. 7
• Never use single-agent therapy for gonorrhea in pregnancy, as resistance patterns and co-infection rates mandate dual therapy. 1, 2
• Never assume partners were treated—directly verify or use expedited partner therapy strategies. 7