What is the recommended treatment for a male patient with uncomplicated gonococcal infection?

Treatment of Uncomplicated Gonococcal Infection in Men

The recommended treatment for uncomplicated gonococcal infection in men is ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 7 days if chlamydial coinfection has not been excluded. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM single dose is the first-line therapy for all sites of uncomplicated gonorrhea (urethral, rectal, and pharyngeal). 1, 2
• Add doxycycline 100 mg orally twice daily for 7 days to cover possible chlamydial coinfection, which occurs in 40-50% of gonorrhea cases. 1, 3
• The increase from 250 mg to 500 mg ceftriaxone dose reflects updated antimicrobial stewardship and concerns about emerging resistance. 2
• Azithromycin 1 g orally as a single dose can be substituted for doxycycline when single-dose therapy is preferred for compliance, though doxycycline is now recommended to reduce azithromycin resistance pressure. 1, 2

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose is the preferred oral alternative, but requires mandatory test-of-cure at 1 week. 1, 4
• Cefixime has declining effectiveness due to rising minimum inhibitory concentrations and should only be used when ceftriaxone is truly unavailable. 1

Severe Cephalosporin Allergy Options

• Azithromycin 2 g orally as a single dose is recommended for patients with severe cephalosporin allergy, with mandatory test-of-cure at 1 week. 1, 4, 5
• This regimen has only 93% efficacy and causes significant gastrointestinal distress (35.3% of patients experience GI side effects, with 2.9% severe). 1, 6
• Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally achieved 100% cure rates in clinical trials and is an effective alternative. 1, 7
• Spectinomycin 2 g IM single dose has 96.7% efficacy for urogenital infections but only 52% for pharyngeal infections and has limited availability. 1, 4

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 1, 4
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections—oral alternatives and gentamicin have poor pharyngeal efficacy (only 20% cure rate for gentamicin). 1
• The 500 mg dose is particularly important for pharyngeal infections due to marked variability in cephalosporin clearance and protein binding in tonsillar tissue. 1

Critical Management Components

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia with the same dual therapy regimen. 1, 4
• Patients and partners must abstain from sexual intercourse until therapy is completed and both are asymptomatic. 1
• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation. 1

Follow-Up Requirements

• Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist. 8, 1
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy. 1, 4, 5
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 1, 4
• Consider retesting all patients at 3 months due to high reinfection risk (most post-treatment infections are reinfections, not treatment failures). 8, 1

Treatment Failure Management

• If treatment failure is suspected, obtain specimens for culture and antimicrobial susceptibility testing immediately. 1
• Report the case to local public health officials within 24 hours and consult an infectious disease specialist. 1
• Recommended salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally or ertapenem 1 g IM for 3 days. 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates. 8, 1, 2
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy and risks rapid resistance emergence. 1, 5, 9
• Do not skip partner treatment, as this is the primary cause of apparent treatment failure and reinfection. 1
• Avoid spectinomycin and gentamicin for pharyngeal infections due to poor efficacy at this site. 1

Additional Testing Recommendations

• Screen for syphilis with serology at the time of gonorrhea diagnosis. 1
• Perform HIV co-testing, as gonorrhea facilitates HIV transmission and increases HIV shedding. 1, 2