Gonorrhea Treatment Guidelines
Current Treatment Recommendations
- The Centers for Disease Control and Prevention (CDC) recommends ceftriaxone 250 mg intramuscularly as a single dose PLUS azithromycin 1 g orally as a single dose for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea 1, 2, 3
- Azithromycin is strongly preferred over doxycycline as the second agent due to substantially higher prevalence of gonococcal tetracycline resistance, particularly in strains with elevated cefixime MICs 1, 4
Doxycycline's Limited Role
- Doxycycline 100 mg orally twice daily for 7 days may be used as an alternative second antimicrobial with ceftriaxone, but only when azithromycin is not preferred 1, 2, 3
- Among Gonococcal Isolate Surveillance Project (GISP) isolates with elevated cefixime MICs, 77.2% exhibited tetracycline resistance while only 0.6% had decreased susceptibility to azithromycin 4
Resistance Patterns
- High prevalence of tetracycline resistance among N. gonorrhoeae isolates makes doxycycline unreliable as monotherapy 1, 4, 5
Critical Caveats
- If ceftriaxone is not available, use cefixime 400 mg orally PLUS azithromycin 1 g orally (or doxycycline 100 mg twice daily for 7 days) PLUS mandatory test-of-cure in 1 week 1, 2
- For patients with severe cephalosporin allergy, azithromycin 2 g orally as a single dose PLUS test-of-cure in 1 week is recommended 1, 2