What is the recommended treatment for someone exposed to gonorrhea?

Treatment for Gonorrhea Exposure

Treat all individuals exposed to gonorrhea with the same dual therapy regimen used for confirmed infection: ceftriaxone 500 mg IM plus doxycycline 100 mg orally twice daily for 7 days (or azithromycin 1 g orally as a single dose if compliance is uncertain). 1, 2

Rationale for Presumptive Treatment

• Gonorrhea transmission rates are high enough to warrant immediate treatment without waiting for test results, particularly because many infections are asymptomatic and patients may not return for follow-up 3
• Co-infection with Chlamydia trachomatis occurs in 10-50% of gonorrhea cases, making dual therapy essential even for presumptive treatment 3, 1
• The CDC explicitly recommends that all sexual partners from the preceding 60 days should be evaluated and treated for both gonorrhea and chlamydia, regardless of symptoms or test results 1

Recommended Treatment Regimen

Primary regimen:

• Ceftriaxone 500 mg IM as a single dose 1, 2
• PLUS doxycycline 100 mg orally twice daily for 7 days 2

Alternative if compliance is a concern:

• Ceftriaxone 500 mg IM as a single dose 1
• PLUS azithromycin 1 g orally as a single dose 1

The azithromycin option provides single-dose convenience but is less preferred due to antimicrobial stewardship concerns and increasing azithromycin resistance 2. However, for exposed partners who may not complete a 7-day course, the single-dose regimen is more practical 1.

Special Considerations for Partner Management

• Expedited partner therapy (EPT) may be considered when partners cannot be linked to timely evaluation, using oral combination therapy: cefixime 400 mg plus azithromycin 1 g orally 1, 4, 5
• EPT is NOT recommended for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV 1
• Partners should avoid sexual intercourse until therapy is completed and both individuals are asymptomatic 1

Critical Pitfalls to Avoid

• Never use quinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment or prophylaxis due to widespread resistance, despite their historical effectiveness 1, 2
• Never use azithromycin 1 g alone for gonorrhea treatment—it has only 93% efficacy and risks rapid resistance emergence 1
• Do not use cefixime as first-line therapy—it is only acceptable when ceftriaxone is unavailable, and requires mandatory test-of-cure at 1 week 1, 4

Pregnancy Considerations

• Pregnant women exposed to gonorrhea should receive the same dual therapy: ceftriaxone 500 mg IM plus azithromycin 1 g orally 1, 6, 7
• Never use doxycycline, quinolones, or tetracyclines in pregnancy 1

Follow-Up Requirements

• Patients treated with the recommended ceftriaxone-based regimen do not need routine test-of-cure unless symptoms develop 1, 6
• Retest all patients at 3 months due to high reinfection risk (most "treatment failures" are actually reinfections) 1, 6, 7
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately 1

Transmissibility Context

• Gonorrhea is highly transmissible, with transmission occurring even from asymptomatic individuals 3
• Many infections in women remain asymptomatic until complications like pelvic inflammatory disease develop, which can lead to tubal scarring, infertility, or ectopic pregnancy 3
• The high transmissibility and potential for serious sequelae justify aggressive partner treatment strategies 2