From the Guidelines
The first line treatment for gonorrhea is a dual therapy approach consisting of a single intramuscular dose of ceftriaxone 250 mg plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days. This combination therapy is recommended due to increasing antibiotic resistance patterns observed in Neisseria gonorrhoeae, as reported by the CDC in 2012 1. Ceftriaxone, a third-generation cephalosporin, targets the bacterial cell wall synthesis, while azithromycin, a macrolide antibiotic, inhibits bacterial protein synthesis, providing complementary mechanisms of action.
Key Considerations
- Patients should abstain from sexual activity for 7 days after treatment completion and until all symptoms have resolved.
- All recent sexual partners (within the past 60 days) should be notified, tested, and treated regardless of symptoms.
- It's essential to test for other sexually transmitted infections, particularly chlamydia, HIV, and syphilis, as co-infections are common.
- Follow-up testing to confirm cure is recommended in certain cases, such as persistent symptoms or high risk of reinfection.
- Patients should also be counseled on safe sex practices, including consistent condom use to prevent reinfection. The CDC's recommendation for combination therapy is based on data from the Gonococcal Isolate Surveillance Project (GISP), which has monitored Neisseria gonorrhoeae antimicrobial susceptibilities since 1986 1. The increasing resistance to cephalosporins, particularly cefixime, has led to the recommendation of ceftriaxone as the primary treatment option 1.
From the FDA Drug Label
1.5 Uncomplicated Gonorrhea (cervical/urethral) Cefixime for oral suspension and cefixime capsule is indicated in the treatment of adults and pediatric patients six months of age or older with uncomplicated gonorrhea (cervical/urethral) caused by susceptible isolates of Neisseria gonorrhoeae(penicillinase-and non-penicillinase-producing isolates).
2.1 Adults The recommended dose of cefixime is 400 mg daily. This may be given as a 400 mg capsule daily. For the treatment of uncomplicated cervical/urethral gonococcal infections, a single oral dose of 400 mg is recommended.
First line treatment for gonorrhea is cefixime, with a recommended dose of 400 mg as a single oral dose for adults with uncomplicated cervical/urethral gonococcal infections 2.
- Key points:
- Cefixime is indicated for the treatment of uncomplicated gonorrhea (cervical/urethral) caused by susceptible isolates of Neisseria gonorrhoeae.
- The recommended dose for adults is 400 mg as a single oral dose.
- Cefixime should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria.
From the Research
First Line Treatment for Gonorrhea
- The first line treatment for gonorrhea is dual therapy with ceftriaxone and azithromycin, as recommended by the American College of Obstetricians and Gynecologists (ACOG) in 2015 3.
- However, due to the increasing resistance of Neisseria gonorrhoeae to azithromycin, the Centers for Disease Control and Prevention (CDC) updated its treatment guidelines in 2020 to recommend a single 500 mg intramuscular dose of ceftriaxone for the treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 4, 5.
- If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended 4, 5.
- A study published in 2024 compared the efficacy of single-dose cefixime 800 mg plus doxycycline 100 mg twice a day for 7 days with single-dose ceftriaxone 1 g plus single-dose azithromycin 2 g for the treatment of urogenital, rectal, and pharyngeal gonorrhea, and found that the combination of cefixime and doxycycline did not achieve noninferiority to ceftriaxone and azithromycin for the treatment of gonorrhea when including pharyngeal gonorrhea 6.
- Another study published in 2018 evaluated the in vitro efficacy of 21 dual antimicrobial combinations, including current and alternative WHO recommended treatment regimens, and found that the WHO recommended combinations of cefixime plus azithromycin and ceftriaxone plus azithromycin had no antagonism, indicating their continuing clinical utility 7.