What is the recommended treatment for a patient diagnosed with gonorrhea and chlamydia?

Treatment for Gonorrhea and Chlamydia

For patients diagnosed with both gonorrhea and chlamydia, treat with ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1

Primary Recommended Regimen

• Ceftriaxone 500 mg IM (single dose) PLUS doxycycline 100 mg orally twice daily for 7 days is the current standard of care for dual infection 1
• This regimen achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 2
• Co-infection rates are extremely high (40-50% of gonorrhea patients also have chlamydia), making dual therapy essential even when only one organism is confirmed 3, 2

Alternative Single-Dose Regimen (When 7-Day Therapy Not Feasible)

• Ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) can be used when compliance with multi-day therapy is unlikely 2, 4, 5
• This regimen should be administered together on the same day, preferably simultaneously and under direct observation 4, 5
• While azithromycin 1 g is effective for chlamydia as a single dose, it has only 93% efficacy against gonorrhea when used alone and should never be used as monotherapy 3

Alternative Oral Regimen (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally (single dose) PLUS doxycycline 100 mg orally twice daily for 7 days 2, 6
• This regimen requires mandatory test-of-cure at 1 week due to inferior efficacy compared to ceftriaxone 2, 7
• Cefixime has lower efficacy for pharyngeal gonorrhea (78.9%) compared to ceftriaxone 3

Site-Specific Considerations

Pharyngeal Infections

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections 3
• Ceftriaxone 125-500 mg IM is the most reliable option for pharyngeal infections 3, 2
• Cefuroxime axetil has unacceptable efficacy (56.9%) for pharyngeal infections and should not be used 3
• Spectinomycin has only 52% efficacy for pharyngeal infections and should never be used if pharyngeal exposure is suspected 3, 7

Urogenital and Anorectal Infections

• Standard dual therapy with ceftriaxone plus doxycycline or azithromycin is highly effective 1
• Treatment for both gonorrhea and chlamydia is recommended even if chlamydial coinfection of the pharynx is unusual, because coinfection at genital sites frequently occurs 3

Critical Pitfalls to Avoid

Quinolone Resistance

• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) should NOT be used for gonorrhea treatment due to widespread resistance 3, 2
• Quinolones are particularly contraindicated in men who have sex with men (MSM), where resistance rates reached 23.9% by 2004 3
• Quinolones should not be used for infections acquired in California, Hawaii, or through foreign travel 3

Azithromycin Monotherapy

• Azithromycin 1 g alone should never be used for gonorrhea treatment due to insufficient efficacy (only 93% cure rate) 3, 2
• Azithromycin 2 g orally is effective against gonorrhea but causes gastrointestinal distress in 35% of patients and is not recommended 3, 7

Inadequate Regimens

• Penicillins, tetracyclines, and macrolides (erythromycin) are no longer effective against N. gonorrhoeae in the United States 3
• Cefuroxime axetil does not meet minimum efficacy criteria (95.9%) for urogenital/rectal infection 3

Special Populations

Pregnancy

• Pregnant women should receive ceftriaxone 500 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) 2, 7, 4, 5
• Never use quinolones, doxycycline, or tetracyclines in pregnancy 3, 7, 8
• For chlamydia coverage when azithromycin cannot be used, amoxicillin 500 mg three times daily for 7 days is an alternative 7
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 4, 5

Severe Cephalosporin Allergy

• Spectinomycin 2 g IM can be used for urogenital and anorectal infections 3, 7
• Spectinomycin is unreliable (52% effective) for pharyngeal infections and requires pharyngeal culture 3-5 days after treatment to verify eradication 3
• Azithromycin 2 g orally single dose is an option but requires test-of-cure at 1 week 7

Men Who Have Sex With Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains 3, 9
• Quinolones should never be used in this population 3

Follow-Up Requirements

Test-of-Cure

• Routine test-of-cure is NOT needed for patients treated with recommended ceftriaxone-based regimens unless symptoms persist 3, 2, 4, 5
• Test-of-cure IS mandatory at 1 week for patients receiving cefixime-based regimens or azithromycin monotherapy 2, 7
• Patients with persistent symptoms should be evaluated by culture for N. gonorrhoeae with antimicrobial susceptibility testing 3

Retesting for Reinfection

• All patients should be retested approximately 3 months after treatment due to high reinfection risk (not treatment failure) 3, 2, 7, 4, 5
• The majority of infections identified after treatment with recommended regimens result from reinfection rather than treatment failure 3
• If patients do not return at 3 months, test whenever they next seek care within 12 months 3

Partner Management

• All sexual partners from the preceding 60 days should be evaluated and treated for both N. gonorrhoeae and C. trachomatis 3, 7
• If last sexual intercourse was >60 days before symptom onset or diagnosis, treat the most recent sex partner 3
• Patients should abstain from sexual intercourse until therapy is completed and both patient and partners are asymptomatic 3, 7
• For patients receiving single-dose therapy, abstain for 7 days after treatment 3
• Expedited partner therapy (delivering prescriptions or medications directly to partners) is an option when partners cannot be linked to timely evaluation 3, 9

Concurrent Testing Requirements

• All patients tested for gonorrhea should be tested for chlamydia, syphilis, and HIV 3, 9
• If chlamydial test results are not available at the time of gonorrhea treatment, presumptive treatment for chlamydia is indicated 3
• Patients with negative chlamydial NAAT at the time of gonorrhea treatment do not need additional chlamydia treatment 3