What is the recommended treatment for a sexually active individual, likely between 15 and 35 years old, with a possible history of other sexually transmitted infections (STIs), diagnosed with gonorrhea?

Gonorrhea Treatment

Primary Treatment Recommendation

Treat with ceftriaxone 500 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx. 1

This dual therapy regimen is the current standard of care, addressing both gonorrhea and presumptive chlamydial co-infection, which occurs in 10-50% of cases. 1, 2

Rationale for Dual Therapy

• Dual antimicrobial therapy is mandatory to improve treatment efficacy and potentially delay emergence of cephalosporin resistance, given rising antibiotic resistance patterns globally. 1
• The combination addresses the extremely common co-infection with Chlamydia trachomatis (40-50% of gonorrhea cases), making presumptive treatment essential. 1
• Azithromycin is preferred over doxycycline due to single-dose convenience, superior compliance, and substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin. 1

Alternative Regimens (When Ceftriaxone Unavailable)

• Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose, with mandatory test-of-cure at 1 week due to declining effectiveness and rising cefixime MICs. 1, 3
• For severe cephalosporin allergy: Azithromycin 2 g orally in a single dose, with mandatory test-of-cure at 1 week (note: lower efficacy at 93% and high gastrointestinal side effects). 1
• Gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally single dose is an alternative with 100% cure rate in clinical trials. 1

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates. 1, 2, 4
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy and risks rapid resistance emergence. 1, 2
• Never use cefixime as monotherapy without azithromycin or doxycycline—this violates dual therapy recommendations. 1
• Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided when pharyngeal infection is suspected. 5, 1

Site-Specific Considerations

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections. 1
• Ceftriaxone 500 mg IM is the only reliably effective treatment for pharyngeal infections, with superior efficacy compared to all oral alternatives. 1
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites. 1

Special Populations

Pregnancy

• Use ceftriaxone (preferred cephalosporin) PLUS azithromycin 1 g orally—never use quinolones or tetracyclines in pregnancy. 5, 1
• If cephalosporin cannot be tolerated, spectinomycin 2 g IM single dose is an option. 5

Men Who Have Sex with Men (MSM)

• Ceftriaxone is the only recommended treatment for MSM due to higher prevalence of resistant strains. 1
• Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV. 5, 1

Patients with Recent Foreign Travel

• Ceftriaxone 500 mg IM is the superior choice due to increased risk of resistant strains. 1

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days for both gonorrhea and chlamydia with the same dual therapy regimen. 5, 1
• Partners should receive ceftriaxone 500 mg IM plus azithromycin 1 g orally. 1
• Expedited partner therapy (cefixime 400 mg plus azithromycin 1 g orally) may be considered when partners cannot be linked to timely evaluation, but not for MSM. 5, 1
• Patients must avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic. 5, 1

Follow-Up Requirements

• Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist. 5, 1
• Mandatory test-of-cure at 1 week is required for patients receiving cefixime or azithromycin monotherapy due to lower efficacy. 1
• Consider retesting all patients at 3 months due to high reinfection risk (most post-treatment infections result from reinfection rather than treatment failure). 5, 1
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately. 5, 1

Treatment Failure Management

• Obtain specimens for culture and antimicrobial susceptibility testing immediately if treatment failure is suspected. 1
• Report the case to local public health officials within 24 hours. 1
• Consult an infectious disease specialist. 1
• Recommended salvage regimens include: gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose), spectinomycin 2 g IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days. 1

Additional Screening Recommendations

• Screen for syphilis with serology at the time of gonorrhea diagnosis. 1
• Co-test for HIV given that gonorrhea facilitates HIV transmission. 1
• Screen for other sexually transmitted infections as clinically indicated. 4, 6