What is the recommended treatment for a male patient with gonorrhea and chlamydia who is allergic to penicillin (antibiotic) and cephalosporin (antibiotic)?

Treatment for Gonorrhea and Chlamydia in Penicillin and Cephalosporin Allergic Male

For a male patient with gonorrhea and chlamydia who is allergic to both penicillin and cephalosporins, treat with azithromycin 2 g orally as a single dose for gonorrhea PLUS doxycycline 100 mg orally twice daily for 7 days for chlamydia, with mandatory test-of-cure at 1 week. 1, 2

Critical Treatment Considerations

Why This Regimen

• Azithromycin 2 g (not 1 g) is the only oral alternative for gonorrhea in patients with severe cephalosporin allergy, achieving 98.9% cure rates in clinical trials 3, 1
• Azithromycin 1 g alone is explicitly contraindicated for gonorrhea treatment, with only 93% efficacy and concerns about rapid resistance emergence 1, 2
• Doxycycline 100 mg twice daily for 7 days is the standard treatment for chlamydia and must be added separately since azithromycin 2 g alone does not reliably cover both infections 4, 5

Important Limitations and Warnings

• Gastrointestinal side effects are common with azithromycin 2 g, occurring in 35.3% of patients (10.1% moderate, 2.9% severe), which may affect compliance 3, 1
• Mandatory test-of-cure at 1 week is required for all patients receiving azithromycin 2 g for gonorrhea, as this is not a first-line regimen 1, 2
• The CDC specifically warns against widespread use of azithromycin monotherapy due to emerging macrolide resistance concerns 6, 1

Alternative Regimen for Severe Cases

If injectable therapy is acceptable despite cephalosporin allergy:

• Gentamicin 240 mg IM plus azithromycin 2 g orally achieves 100% cure rates for urogenital gonorrhea 7, 1
• However, gentamicin has poor pharyngeal efficacy (only 80% cure rate vs. 96% for ceftriaxone), making it unsuitable if pharyngeal infection is present or suspected 8, 9
• Gentamicin alone is completely inadequate for pharyngeal gonorrhea, with only 20% efficacy in one study 10

Site-Specific Concerns

Pharyngeal Infection

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital infections and serves as a critical reservoir for antimicrobial resistance 1, 2
• Most documented treatment failures with alternative regimens involve pharyngeal sites, not urogenital sites 1, 2
• If pharyngeal infection is suspected or confirmed, azithromycin 2 g is the only viable oral option in cephalosporin-allergic patients, though efficacy data are limited 1

Urogenital and Rectal Infections

• Gentamicin 240 mg IM plus azithromycin 2 g is highly effective for isolated genital infections (94% cure rate) 8, 7
• Rectal infections show 90% cure rates with gentamicin/azithromycin vs. 98% with ceftriaxone 8, 9

Follow-Up Requirements

Mandatory Test-of-Cure

• Perform NAAT testing at 1 week post-treatment for all patients receiving non-cephalosporin regimens 1, 2
• If NAAT is positive at follow-up, confirm with culture and perform antimicrobial susceptibility testing 1
• Report any treatment failures to local public health officials within 24 hours and consult an infectious disease specialist 1

Additional Testing

• Retest at 3 months due to high reinfection risk (10-50% of patients) 1
• Screen for syphilis with serology at the time of gonorrhea diagnosis 1
• Perform HIV testing given facilitation of HIV transmission by gonorrhea 1

Partner Management

• All sexual partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia, regardless of symptoms 1, 2
• Partners should receive the same dual therapy regimen (azithromycin 2 g plus doxycycline 100 mg twice daily for 7 days if cephalosporin-allergic) 1
• Patients must avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1

Common Pitfalls to Avoid

• Never use azithromycin 1 g alone for gonorrhea—it is explicitly contraindicated by CDC guidelines with only 93% efficacy 1, 2
• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance, despite historical effectiveness 1, 2
• Never skip test-of-cure when using alternative regimens—all non-cephalosporin regimens require mandatory follow-up 1, 2
• Never assume oral therapy is equivalent to injectable ceftriaxone, particularly for pharyngeal infections 2
• Do not use spectinomycin if available, as it has only 52% efficacy for pharyngeal infections 1, 11

Clinical Decision Algorithm

1. Confirm allergy severity: True IgE-mediated allergy vs. intolerance
2. Assess infection sites: Urogenital only vs. pharyngeal/rectal involvement
3. If urogenital only and injectable acceptable: Gentamicin 240 mg IM + azithromycin 2 g orally
4. If pharyngeal/rectal or oral only: Azithromycin 2 g orally + doxycycline 100 mg twice daily × 7 days
5. Schedule mandatory test-of-cure at 1 week
6. Treat and test all partners from preceding 60 days
7. Retest patient at 3 months for reinfection