What is the recommended management of gonorrhea in an adult patient (any gender), including first‑line therapy, treatment for possible chlamydial co‑infection, alternatives for cephalosporin allergy, regimen for pregnant women, partner treatment, and follow‑up testing?

Management of Gonorrhea

First-Line Treatment

The recommended treatment for uncomplicated gonorrhea is ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose, administered together on the same day, preferably simultaneously and under direct observation. 1, 2

• This dual therapy addresses both gonorrhea and presumptive chlamydial co-infection, which occurs in 20-50% of cases 1
• The 500 mg dose of ceftriaxone (increased from the previous 250 mg recommendation) is particularly important for pharyngeal infections, which are more difficult to eradicate than urogenital or anorectal sites 1, 2
• Azithromycin is strongly preferred over doxycycline due to single-dose convenience, superior compliance, and substantially higher cure rates 1
• Both medications should be given simultaneously under direct observation to ensure adherence 3

Alternative Regimens

When Ceftriaxone is Unavailable

If ceftriaxone cannot be obtained, use cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose, with mandatory test-of-cure at 1 week. 1

• Cefixime has lower efficacy (97.4%) compared to ceftriaxone (99.1%) and is particularly unreliable for pharyngeal infections (only 78.9% cure rate) 1
• Test-of-cure is mandatory because of rising cefixime MICs and documented treatment failures in Europe 1

For Severe Cephalosporin Allergy

Patients with documented severe cephalosporin allergy should receive azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week. 1, 4

• This regimen has lower efficacy (93%) and high gastrointestinal side effects (35.3% of patients experience GI symptoms, with 2.9% severe) 1, 5
• Alternative option: spectinomycin 2 g intramuscularly as a single dose, but this has only 52% efficacy for pharyngeal infections and should be avoided for suspected pharyngeal gonorrhea 6, 1, 4
• Gentamicin 240 mg intramuscularly PLUS azithromycin 2 g orally is another alternative with 100% cure rate in clinical trials, though gentamicin has poor pharyngeal efficacy (only 20%) 1

Treatment for Chlamydial Co-Infection

All patients treated for gonorrhea must receive concurrent treatment for chlamydia unless chlamydial infection has been definitively excluded by testing. 1, 2

• First-line: Azithromycin 1 g orally as a single dose 1
• Alternative: Doxycycline 100 mg orally twice daily for 7 days (if azithromycin is contraindicated or unavailable) 2
• Never omit chlamydia treatment even when chlamydia testing is negative, due to the extremely high co-infection rate 1

Pregnancy Considerations

Pregnant women with gonorrhea should receive ceftriaxone 500 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose. 1, 3

• Never use quinolones, tetracyclines, or doxycycline in pregnancy due to fetal safety concerns 6, 1
• For pregnant women who cannot tolerate cephalosporins: spectinomycin 2 g intramuscularly as a single dose PLUS azithromycin 1 g orally 6
• Alternative chlamydia treatment in pregnancy: amoxicillin 500 mg orally three times daily for 7 days 1
• Pregnant women with antenatal gonococcal infection should be retested in the third trimester unless recently treated 3

Partner Management

All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen (ceftriaxone 500 mg IM plus azithromycin 1 g orally), regardless of symptoms or test results. 6, 1

• If the patient is symptomatic and last sexual contact was within 30 days of symptom onset, partners should be treated 6
• If the patient is asymptomatic, partners whose last contact was within 60 days of diagnosis should be treated 6
• If last intercourse occurred before these time periods, treat the most recent partner 6

Expedited Partner Therapy (EPT)

When partners cannot be linked to timely clinical evaluation, consider expedited partner therapy with oral combination therapy: cefixime 400 mg plus azithromycin 1 g. 1, 4

• EPT reduces retreatment rates by 45% compared to standard partner referral 7
• Do NOT use EPT for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV infection 6, 1
• Patients delivering EPT must inform female partners about the importance of seeking medical evaluation for possible pelvic inflammatory disease 6

Sexual Activity Restrictions

Patients must abstain from sexual intercourse until therapy is completed and both they and all partners are asymptomatic. 6, 1

Follow-Up Testing

Test-of-Cure

Patients treated with recommended ceftriaxone-based regimens do NOT need routine test-of-cure unless symptoms persist. 6, 1, 2

• Mandatory test-of-cure at 1 week is required for:

  • Patients receiving cefixime-based regimens 1
  • Patients receiving azithromycin 2 g monotherapy 1
  • Patients with suspected pharyngeal infection treated with spectinomycin 6

• Test-of-cure should ideally use culture (allows antimicrobial susceptibility testing) or nucleic acid amplification testing (NAAT) if culture is unavailable 1

• If NAAT is positive at follow-up, confirm with culture and perform phenotypic antimicrobial susceptibility testing 1

Retesting for Reinfection

All patients should be retested 3 months after treatment due to high reinfection rates (approximately 10% within 2 years). 1, 3, 8

• Most post-treatment infections result from reinfection rather than treatment failure 6, 7

Management of Persistent Symptoms or Treatment Failure

If symptoms persist after treatment with a recommended regimen, immediately obtain specimens for culture with antimicrobial susceptibility testing from all potentially infected sites. 1, 2

1. Collect culture specimens from all potentially infected sites (urethra, cervix, rectum, pharynx) 1
2. Report suspected treatment failure to local public health officials within 24 hours 1, 4
3. Consult an infectious disease specialist 1, 4
4. Re-treat with salvage regimens:
   • Gentamicin 240 mg IM PLUS azithromycin 2 g orally (single dose) 1
   • Ertapenem 1 g IM for 3 days 1
   • Spectinomycin 2 g IM PLUS azithromycin 2 g orally 1

Special Population Considerations

Men Who Have Sex with Men (MSM)

MSM should receive only ceftriaxone-based regimens due to higher prevalence of resistant strains. 1

• Never use quinolones for MSM due to widespread resistance 1
• Do not use expedited partner therapy for MSM 6, 1

Patients with Recent Foreign Travel

Patients with recent foreign travel should receive ceftriaxone 500 mg IM (not oral alternatives) due to increased risk of resistant strains. 1

HIV-Infected Patients

Patients with HIV infection should receive the same treatment regimen as HIV-negative patients. 6

Site-Specific Considerations

Pharyngeal Gonorrhea

Pharyngeal infections are significantly more difficult to eradicate and require ceftriaxone 500 mg IM—oral cephalosporins are unreliable. 1

• Cefixime achieves only 78.9% cure rate for pharyngeal infections 1
• Spectinomycin has only 52% efficacy for pharyngeal sites 6, 1
• Gentamicin has only 20% cure rate for pharyngeal infections 1
• Most ceftriaxone treatment failures involve the pharynx, not urogenital sites 1

Gonococcal Conjunctivitis

Treat with ceftriaxone 1 g intramuscularly as a single dose and lavage the infected eye with saline solution once. 6

Disseminated Gonococcal Infection (DGI)

Hospitalization is recommended for initial therapy, especially for patients with uncertain diagnosis, poor compliance risk, or purulent synovial effusions. 6

• Initial regimen: Ceftriaxone 1 g IM or IV every 24 hours 6
• Alternative for β-lactam allergy: Spectinomycin 2 g IM every 12 hours 6
• Continue parenteral therapy for 24-48 hours after improvement begins 6
• Switch to oral therapy to complete 1 week total: Cefixime 400 mg orally twice daily 6
• Examine for clinical evidence of endocarditis and meningitis 6
• Treat presumptively for concurrent chlamydial infection 6

Critical Contraindications and Pitfalls

Never Use These Regimens

Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are absolutely contraindicated for gonorrhea treatment due to widespread resistance, despite historical cure rates of 99.8%. 6, 1, 2, 8

Azithromycin 1 g alone is contraindicated as monotherapy for gonorrhea due to only 93% efficacy and rapid resistance emergence. 1, 5

Cefixime should never be used as monotherapy without azithromycin or doxycycline—this violates dual therapy recommendations. 1

Common Pitfalls to Avoid

• Do not assume symptom resolution equals cure when suboptimal regimens were used—test-of-cure is mandatory for non-ceftriaxone regimens 1
• Do not omit chlamydia treatment even when testing is negative 1
• Do not use oral cephalosporins for pharyngeal infections—they are unreliable 1
• Do not use spectinomycin for suspected pharyngeal infections 6, 1

Additional Screening Recommendations

At the time of gonorrhea diagnosis, screen for syphilis with serology and perform HIV testing, as gonorrhea facilitates HIV transmission. 1