Should an asymptomatic adult sexual partner (including pregnant women) of a patient with confirmed gonorrhea be treated, and what is the recommended regimen?

Treatment of Asymptomatic Sexual Partners of Gonorrhea Patients

Yes, treat all asymptomatic sexual partners of patients with confirmed gonorrhea immediately with the same dual-therapy regimen used for the index case, without waiting for test results. 1, 2

Partner Treatment Algorithm

Time-Based Treatment Criteria

Treat partners based on timing of last sexual contact:

• If index patient is symptomatic: Treat all partners whose last sexual contact occurred within 30 days of symptom onset 1
• If index patient is asymptomatic: Treat all partners whose last sexual contact occurred within 60 days of diagnosis 1, 2
• If last contact predates these windows: Still treat the most recent partner regardless of timing 1, 2

Recommended Treatment Regimen for Partners

Standard dual therapy (same as index patient):

• Ceftriaxone 500 mg intramuscularly as a single dose PLUS
• Azithromycin 1 g orally as a single dose 2, 3

This regimen covers both gonorrhea and presumptive chlamydial coinfection, which occurs in 20-50% of gonorrhea cases 2, 3

Rationale for Treating Asymptomatic Partners

High transmission risk and serious sequelae justify empiric treatment:

• Gonorrhea is highly transmissible even from asymptomatic individuals 3
• Many infections remain asymptomatic until complications develop (pelvic inflammatory disease, infertility, ectopic pregnancy) 3, 4
• Most post-treatment infections represent reinfection rather than treatment failure, emphasizing the critical importance of partner treatment 1
• Partners may not return for follow-up if treatment is delayed pending test results 3

Alternative Delivery Methods

Expedited Partner Therapy (EPT)

When partners cannot access timely clinical evaluation:

• Provide cefixime 400 mg orally plus azithromycin 1 g orally for partner self-administration 2, 3
• Do NOT use EPT for men who have sex with men (MSM) due to high risk of undiagnosed coexisting STDs or HIV 2, 3
• Female partners receiving EPT must be counseled to seek clinical evaluation for possible pelvic inflammatory disease 2

Special Population Considerations

Pregnant Partners

Use ceftriaxone-based regimen with specific precautions:

• Ceftriaxone 500 mg intramuscularly plus azithromycin 1 g orally as a single dose 1, 2
• Never use quinolones, tetracyclines, or doxycycline in pregnancy due to fetal safety concerns 1, 2, 3
• If severe cephalosporin allergy exists: spectinomycin 2 g intramuscularly plus azithromycin 1 g orally 1, 2

Partners with Severe Cephalosporin Allergy

Alternative regimen with mandatory follow-up:

• Azithromycin 2 g orally as a single dose 2, 3
• Mandatory test-of-cure at 1 week (this regimen has only ~93% efficacy and high gastrointestinal side effects) 2, 3
• Consider infectious disease consultation 3

Critical Management Steps

Sexual Activity Restrictions

Partners must abstain from sexual intercourse until:

• Therapy is completed for both index patient and all partners AND
• Both patient and all partners are asymptomatic 1, 2, 3

Follow-Up Testing

Test-of-cure requirements:

• NOT routinely required for partners treated with recommended ceftriaxone-based dual therapy 2, 3
• Mandatory at 1 week for partners treated with alternative regimens (cefixime-based or azithromycin 2 g monotherapy), ideally using culture to allow antimicrobial susceptibility testing 2, 3
• Retest all partners at 3 months due to high reinfection rates (20-30%) 2, 3

Additional Screening

Screen partners for coexisting infections:

• Test for syphilis by serology at time of gonorrhea diagnosis 1, 2
• Test for HIV given that gonorrhea facilitates HIV transmission 2, 3

Common Pitfalls to Avoid

Never use the following contraindicated medications:

• Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) are absolutely contraindicated due to widespread resistance, despite historical cure rates >99% 2, 3, 5, 6
• Azithromycin 1 g alone is insufficient (only 93% efficacy) and promotes rapid resistance 2, 3
• Cefixime as first-line therapy should only be used when ceftriaxone is unavailable, and requires mandatory test-of-cure 2, 3

Do not delay treatment:

• Treat partners immediately upon notification, without waiting for their own test results 1, 2, 3
• The high transmission rate and potential for serious complications (infertility, disseminated infection) outweigh any benefit of awaiting confirmatory testing 3, 4