What is the recommended treatment for a patient with gonorrhea, considering potential co-infections and possible allergies or pregnancy?

Gonorrhea Treatment

Treat all gonorrhea cases with ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days (if chlamydial co-infection has not been excluded). 1

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) is the only recommended first-line treatment for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea. 1
• Add doxycycline 100 mg orally twice daily for 7 days if chlamydial infection has not been ruled out, as co-infection occurs in 40-50% of gonorrhea cases. 2, 1
• Azithromycin 1 g orally (single dose) can replace doxycycline for chlamydia coverage when single-dose therapy is preferred for compliance reasons. 2
• The 500 mg dose (not 250 mg) is now standard due to rising minimum inhibitory concentrations and is particularly critical for pharyngeal infections. 1, 3

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates in 1998. 3, 4
• Never use azithromycin 1 g alone for gonorrhea treatment - it has only 93% efficacy and risks rapid resistance emergence. 5, 3
• Never use cefixime as first-line therapy - it has declining effectiveness and requires mandatory test-of-cure at 1 week. 2, 3
• Spectinomycin has only 52% efficacy against pharyngeal infections and should never be used if pharyngeal exposure is suspected. 5, 3

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) - this is the only safe regimen in pregnancy. 2, 3
• Never use quinolones, tetracyclines, or doxycycline in pregnant women. 5
• If cephalosporin allergy exists, use spectinomycin 2 g IM (single dose), but obtain pharyngeal culture 3-5 days post-treatment due to poor pharyngeal efficacy. 5

Severe Cephalosporin Allergy

• Use gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) - this achieved 100% cure rate in clinical trials. 6, 3
• Alternative: azithromycin 2 g orally alone, but this has lower efficacy (93%) and high gastrointestinal side effects requiring mandatory test-of-cure at 1 week. 3, 7
• Avoid gentamicin for pharyngeal infections - it has only 20% cure rate for pharyngeal gonorrhea. 3

Site-Specific Considerations

Pharyngeal Gonorrhea

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal sites. 5
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections - oral alternatives have substantially lower cure rates. 3, 1
• Spectinomycin and gentamicin both have poor pharyngeal efficacy and should be avoided. 3

Gonococcal Conjunctivitis

• Use ceftriaxone 1 g IM (single dose) PLUS saline lavage of the infected eye once. 5

Disseminated Gonococcal Infection

• Hospitalization is recommended for initial therapy, especially for patients with uncertain diagnosis or purulent synovial effusions. 5
• Treat presumptively for concurrent chlamydial infection unless appropriate testing excludes it. 5

Follow-Up Requirements

• Patients treated with the recommended ceftriaxone 500 mg regimen do NOT need routine test-of-cure unless symptoms persist. 5, 1
• Retest all patients at 3 months after treatment due to high reinfection risk (not treatment failure). 2, 3
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 5, 3
• Report suspected treatment failures to local public health officials within 24 hours and consult an infectious disease specialist. 3

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen for both gonorrhea and chlamydia, regardless of symptoms or test results. 5, 2
• If the patient's last sexual contact was >60 days before symptom onset, treat the most recent partner. 5
• Patients must avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic. 5
• Expedited partner therapy with oral cefixime 400 mg plus azithromycin 1 g may be considered when partners cannot be linked to timely evaluation, but this is NOT recommended for men who have sex with men due to high risk of undiagnosed coexisting STDs or HIV. 3

Treatment Failure Management

• If treatment failure occurs with ceftriaxone, use gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) OR ertapenem 1 g IM for 3 days. 3
• Obtain specimens for culture and antimicrobial susceptibility testing immediately. 3
• Most post-treatment infections result from reinfection rather than treatment failure, indicating need for improved patient education and partner referral. 5

Administration Considerations

• Ceftriaxone should be injected deep into a large muscle mass with aspiration to avoid unintentional vascular injection. 8
• Do not use diluents containing calcium (Ringer's solution, Hartmann's solution) with ceftriaxone due to precipitation risk. 8
• Doxycycline should be administered with adequate fluid and food/milk to reduce esophageal irritation risk. 9