What is the recommended treatment for a 34‑year‑old male with recent gonorrhea exposure, including management of possible chlamydia co‑infection and cephalosporin allergy?

Treatment for 34-Year-Old Male with Recent Gonorrhea Exposure

For a 34-year-old male with recent gonorrhea exposure, administer ceftriaxone 500 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 7 days to cover both gonorrhea and presumptive chlamydia co-infection. 1, 2

Primary Treatment Regimen

• Ceftriaxone 500 mg IM (single dose) is the first-line treatment for uncomplicated gonorrhea at all anatomic sites (urethral, rectal, and pharyngeal) 1, 2
• Doxycycline 100 mg orally twice daily for 7 days should be added if chlamydial infection has not been excluded 1, 2
• This dual therapy addresses the 10-50% co-infection rate between gonorrhea and chlamydia 1, 3

Rationale for This Regimen

• Ceftriaxone achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 1
• The 500 mg dose provides superior efficacy compared to the older 250 mg recommendation, particularly for pharyngeal infections where cephalosporins have marked variability in tissue penetration 1
• Doxycycline is preferred over azithromycin for chlamydia coverage due to antimicrobial stewardship concerns and increasing azithromycin resistance 2

Alternative Regimen (If Ceftriaxone 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 this regimen due to declining cefixime effectiveness (97.4% cure rate vs 99.1% for ceftriaxone) 1, 4

Management of Cephalosporin Allergy

If the patient has a severe cephalosporin allergy, use azithromycin 2 g orally as a single dose for gonorrhea PLUS doxycycline 100 mg orally twice daily for 7 days for chlamydia. 3, 5

Critical Considerations for Allergic Patients

• Azithromycin 2 g achieves 98.9% cure rates for urogenital gonorrhea 6
• Never use azithromycin 1 g alone for gonorrhea—it has only 93% efficacy and risks rapid resistance emergence 1, 3
• Mandatory test-of-cure at 1 week is required for all non-cephalosporin regimens 3, 5
• Gentamicin 240 mg IM plus azithromycin 2 g orally is an alternative with 100% cure rates for urogenital sites, but has poor pharyngeal efficacy 1, 3

Important Caveat About Pharyngeal Infections

• Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital infections 1, 3
• Spectinomycin has only 52% efficacy for pharyngeal sites 7, 5
• Gentamicin has only 20% cure rate for pharyngeal infections 1
• Ceftriaxone is the only reliably effective treatment for pharyngeal gonorrhea 1, 3

Partner Management

• Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen (ceftriaxone 500 mg IM plus doxycycline 100 mg twice daily for 7 days) 1, 5
• Partners should receive treatment regardless of symptoms or test results due to high transmission rates and frequent asymptomatic infections 1
• Patient should avoid sexual intercourse until therapy is completed and both he and his partners are asymptomatic 7, 5
• Consider expedited partner therapy with oral combination (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation 1

Follow-Up Requirements

• Patients treated with recommended ceftriaxone-based regimens do not need routine test-of-cure unless symptoms persist 1, 2
• Consider retesting at 3 months due to 10-50% reinfection risk 1, 3
• If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately 1, 5

Additional Testing at Initial Visit

• Screen for syphilis with serology at the time of gonorrhea diagnosis 1
• Perform HIV testing given that gonorrhea facilitates HIV transmission 1, 2

Critical Pitfalls to Avoid

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) for gonorrhea treatment due to widespread resistance, despite their historical 99.8% cure rates 7, 1, 3
• Never use azithromycin 1 g alone for gonorrhea—it is explicitly contraindicated with only 93% efficacy 7, 1, 3
• Do not use cefixime as monotherapy without azithromycin or doxycycline—this violates dual therapy recommendations 1
• Do not assume oral cephalosporins are equivalent to ceftriaxone—they were removed from first-line recommendations in 2012 due to documented treatment failures in Europe 1

Treatment Failure Management

If treatment failure is suspected:

• Obtain specimens for culture and antimicrobial susceptibility testing immediately 1, 5
• Report the case to local public health officials within 24 hours 1, 5
• Consult an infectious disease specialist 1, 5
• Recommended salvage regimens include gentamicin 240 mg IM plus azithromycin 2 g orally or ertapenem 1 g IM for 3 days 1