What is the recommended treatment regimen for a patient diagnosed with gonorrhea, considering potential co-infections and allergies?

Gonorrhea Treatment

Primary Recommendation

Treat uncomplicated gonorrhea with ceftriaxone 500 mg intramuscularly as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days. 1, 2, 3

Treatment Rationale

Why Dual Therapy is Essential

• Chlamydial co-infection occurs in 40-50% of gonorrhea cases, making presumptive treatment for both organisms mandatory even when chlamydia testing is negative or pending 1, 2
• Dual therapy with different antimicrobial mechanisms potentially delays emergence of cephalosporin resistance 1
• Azithromycin 1 g orally can replace doxycycline when single-dose therapy is preferred for compliance reasons, though doxycycline is now the preferred chlamydia coverage 2, 3

Dosing Specifications

• Ceftriaxone 500 mg IM (not the older 250 mg dose) is the current CDC-recommended dose as of 2020 1, 3
• Doxycycline 100 mg orally twice daily for 7 days provides chlamydia coverage 2, 4
• Both medications should ideally be administered simultaneously under direct observation 1, 5, 6

Alternative Regimens

When Ceftriaxone is Unavailable

• Cefixime 400 mg orally single dose PLUS azithromycin 1 g orally single dose 1
• Mandatory test-of-cure at 1 week is required with cefixime-based regimens due to declining effectiveness (97.4% cure rate vs 98.9% for ceftriaxone) 1

For Severe Cephalosporin Allergy

• Azithromycin 2 g orally as a single dose (not split) 1, 7
• This regimen has only 93% efficacy and high gastrointestinal side effects (35.3% of patients) 1, 8
• Mandatory test-of-cure at 1 week is required 1, 7
• Alternative: Gentamicin 240 mg IM PLUS azithromycin 2 g orally achieves 100% cure rate but has significant GI side effects 1, 9

Site-Specific Considerations

Pharyngeal Gonorrhea

• Pharyngeal infections are significantly more difficult to eradicate than urogenital or anorectal sites 1, 2
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections 1, 2
• Spectinomycin has only 52% efficacy for pharyngeal sites and should be avoided 1
• Gentamicin has only 20% cure rate for pharyngeal infections 1

Urogenital and Anorectal Sites

• Ceftriaxone 500 mg achieves 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1
• Standard dual therapy regimen is effective for all anatomic sites when administered together 1

Special Populations

Pregnancy

• Use ceftriaxone 500 mg IM PLUS azithromycin 1 g orally 1, 2, 5, 6
• Never use quinolones or tetracyclines (including doxycycline) in pregnancy 1, 4
• Azithromycin is the only safe option for chlamydia coverage in pregnancy 1, 5
• Retest in third trimester unless recently treated 5, 6

Men Who Have Sex with Men (MSM)

• Use only ceftriaxone-based regimens due to higher prevalence of resistant strains 1
• Never use quinolones in MSM populations 1
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Patients with Recent Foreign Travel

• Ceftriaxone 500 mg IM is the only recommended treatment due to increased risk of resistant strains 1

Critical Pitfalls to Avoid

Never Use These Regimens

• Fluoroquinolones (ciprofloxacin, ofloxacin) are absolutely contraindicated due to widespread resistance, despite historical 99.8% cure rates 1, 2, 3
• Azithromycin 1 g alone has only 93% efficacy and risks rapid resistance emergence 1, 2, 7
• Cefixime monotherapy without azithromycin or doxycycline violates dual therapy recommendations 1
• Oral cephalosporins are no longer first-line agents due to documented treatment failures in Europe 1

Common Errors

• Using the outdated 250 mg ceftriaxone dose instead of the current 500 mg recommendation 3
• Failing to provide chlamydia coverage when treating gonorrhea 1, 2
• Splitting the 2 g azithromycin dose, which reduces peak serum concentrations and compromises efficacy 7

Follow-Up Requirements

Test-of-Cure

• Patients treated with recommended ceftriaxone 500 mg regimen do NOT need routine test-of-cure unless symptoms persist 1, 2, 5, 6
• Mandatory test-of-cure at 1 week is required for:
  • Cefixime-based regimens 1
  • Azithromycin 2 g monotherapy 1, 7
  • Any alternative regimen 1
• Use culture (preferred, allows antimicrobial susceptibility testing) or NAAT if culture unavailable 1
• If NAAT is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing 1

Reinfection Screening

• Retest all patients at 3 months after treatment due to high reinfection risk (most post-treatment infections result from reinfection, not treatment failure) 1, 2, 5, 6

Persistent Symptoms

• Obtain culture with antimicrobial susceptibility testing immediately 1, 2
• Report suspected treatment failure to local public health officials within 24 hours 1
• Consult infectious disease specialist 1

Partner Management

Evaluation and Treatment

• 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 1, 2
• Partners should receive ceftriaxone 500 mg IM PLUS doxycycline 100 mg orally twice daily for 7 days (or azithromycin 1 g orally if single-dose preferred) 1, 2

Expedited Partner Therapy

• Consider expedited partner therapy with oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1
• Do NOT use expedited partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 1

Sexual Activity Restrictions

• Patients should avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 1

Treatment Failure Management

Immediate Actions

• Collect specimens from all potentially infected sites for culture with antimicrobial susceptibility testing 1
• Report case to local public health officials within 24 hours 1
• Consult infectious disease specialist 1, 2

Salvage Regimens

• Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1, 2
• Ertapenem 1 g IM for 3 days 1, 2
• Spectinomycin 2 g IM PLUS azithromycin 2 g orally (avoid for pharyngeal infections due to 52% efficacy) 1

Additional Screening

• Screen for syphilis with serology at time of gonorrhea diagnosis 1
• Co-test for HIV given facilitation of HIV transmission by gonorrhea 1
• Consider testing for other STIs based on risk factors 1