Treatment for Possible Gonorrhea Exposure

Primary Treatment Regimen

The Centers for Disease Control and Prevention recommends treating possible gonorrhea exposure empirically with ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days), which covers both gonorrhea and presumptive chlamydia coinfection 1, 2
Ceftriaxone 250 mg IM in a single dose is the cornerstone of treatment, combined with concurrent therapy for chlamydia since coinfection rates are high and testing may not be immediately available 1, 2
Azithromycin 1 g orally as a single dose is the preferred second antimicrobial (preferred over doxycycline due to high tetracycline resistance rates) 1, 2

For pharyngeal exposure, the same dual therapy regimen (ceftriaxone 250 mg IM plus azithromycin 1 g orally) is recommended, as pharyngeal gonorrhea is more difficult to eradicate than urogenital infections 1, 2, 3
For rectal exposure, use the identical regimen as for urogenital exposure 1, 2

If ceftriaxone is not readily available, use cefixime 400 mg orally plus azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days), with mandatory test-of-cure at 1 week 1, 2
If severe cephalosporin allergy exists, use azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week and infectious disease consultation 1, 2, 4

Treat all sexual partners from the preceding 60 days, regardless of symptoms or test results 5, 6, 7
Instruct patients to avoid sexual intercourse until therapy is completed and both they and their partners are asymptomatic 5, 6, 7
If partner treatment cannot be ensured, consider expedited partner therapy by delivering cefixime 400 mg plus azithromycin 1 g to the partner (for heterosexual contacts only, not for MSM due to high risk of undiagnosed coexisting STDs) 5, 6, 7

Test-of-cure is NOT routinely recommended for patients treated with the recommended ceftriaxone-based dual therapy regimen 5, 8
Test-of-cure IS mandatory at 1 week for patients treated with alternative regimens (cefixime-based or azithromycin 2 g monotherapy), ideally using culture to allow antimicrobial susceptibility testing 1, 2, 4
Retest all patients at 3 months after treatment due to high reinfection rates (majority of post-treatment infections are reinfections, not treatment failures) 5, 6, 8

Pregnant women should receive ceftriaxone 250 mg IM plus azithromycin 1 g orally (avoid doxycycline and quinolones) 5, 6, 7
HIV-infected patients should use the same treatment regimen as for HIV-negative patients 5, 7

Never use fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) due to widespread resistance in the United States 9, 10
Cefixime is no longer first-line therapy due to declining susceptibility; it should only be used when ceftriaxone is unavailable, and requires test-of-cure 9, 1, 10
For MSM, do not use expedited partner therapy due to high rates of coexisting undiagnosed STDs and HIV infection 5, 6, 7

Dual therapy with two antimicrobials having different mechanisms of action is essential to slow emergence of cephalosporin resistance 9, 10
Ceftriaxone resistance remains rare but surveillance shows concerning trends with elevated MICs, making continued monitoring critical 9, 10