Gonorrhea Treatment Guidelines

Current Standard of Care

The Centers for Disease Control and Prevention (CDC) recommends ceftriaxone 500 mg intramuscularly as the only first-line treatment for uncomplicated gonorrhea at all anatomic sites, with azithromycin 1 g orally added only if chlamydial coinfection has not been excluded 3
Ceftriaxone achieves a 99.1% cure rate for uncomplicated urogenital and anorectal gonorrhea 3
Ceftriaxone is particularly critical for pharyngeal infections, which are significantly more difficult to eradicate than urogenital or anorectal sites 4, 3

Azithromycin 1 g orally has only 93% efficacy against gonorrhea and is explicitly not recommended as monotherapy 1, 2, 3
Even the higher 2 g dose of azithromycin, while effective (98.9% cure rate in one trial), is expensive, causes significant gastrointestinal distress (35.3% of patients experience GI side effects, with 2.9% severe), and is not recommended due to concerns about emerging macrolide resistance 1, 2
The CDC specifically warns against widespread use of azithromycin monotherapy because of antimicrobial resistance concerns 5

Pharyngeal gonorrhea is the Achilles' heel of alternative regimens 4, 3
The pharynx serves as a critical reservoir for antimicrobial resistance development through DNA exchange with commensal Neisseria species 4
Most documented ceftriaxone treatment failures involve pharyngeal infections, not urogenital sites 4, 3

For patients with severe cephalosporin allergy, azithromycin 2 g orally (not 1 g) is the only oral alternative, but requires mandatory test-of-cure at 1 week 3, 6
Alternative regimens for cephalosporin-allergic patients include Gentamicin 240 mg IM plus azithromycin 2 g orally (100% cure rate in clinical trials) 3
Spectinomycin 2 g IM (98.2% cure for urogenital/rectal, but only 52% for pharyngeal) 1, 2, 6

Never use azithromycin 1 g alone for gonorrhea treatment - it is explicitly contraindicated by CDC guidelines 1, 2, 3
Never assume oral therapy is equivalent to injectable ceftriaxone - pharyngeal infections require ceftriaxone for reliable cure 4
Never skip test-of-cure when using alternative regimens - all non-ceftriaxone regimens require mandatory follow-up culture at 1 week 3, 6

All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen for both gonorrhea and chlamydia, regardless of which regimen the index patient received 4, 3