Treatment of Oral Gonorrhea with IM Ceftriaxone

Core Treatment Regimen

The American College of Physicians recommends ceftriaxone 500 mg IM as a single dose PLUS azithromycin 1 g orally as a single dose for the treatment of oral gonorrhea, with superior efficacy compared to all oral alternatives 1
The Centers for Disease Control and Prevention suggests that azithromycin 1 g orally must be added to address potential chlamydial coinfection and to potentially delay emergence of cephalosporin resistance 1
Pharyngeal gonorrhea is significantly more difficult to eradicate than urogenital or anorectal infections, making ceftriaxone the only acceptable first-line agent 2, 1

The standard dose is 500 mg IM, which represents an increase from older guidelines due to antimicrobial stewardship concerns and evolving resistance patterns 1
The azithromycin component is given as a single 1 g oral dose simultaneously 1

The Centers for Disease Control and Prevention recommends screening for syphilis with serology at the time of gonorrhea diagnosis 3
The American College of Physicians suggests treating all sexual partners from the preceding 60 days; if last contact was >60 days before diagnosis, treat the most recent partner 1, 3
Patients should be instructed to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1

The Centers for Disease Control and Prevention advises against using quinolones (ciprofloxacin, ofloxacin) due to widespread resistance 4, 1
Azithromycin 1 g alone has only 93% efficacy, which is inadequate 5, 1
Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for oral gonorrhea 1, 3
Gentamicin has only 20% cure rate for pharyngeal infections 1

Patients treated with the recommended ceftriaxone 500 mg IM + azithromycin 1 g regimen do not need routine test-of-cure unless symptoms persist 2, 1
Consider retesting at 3 months due to high reinfection risk 1

For severe cephalosporin allergy, use azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week 5, 1
In pregnancy, use the standard regimen: ceftriaxone 500 mg IM PLUS azithromycin 1 g orally, and never use quinolones or tetracyclines 1, 3
For men who have sex with men (MSM), only use ceftriaxone and never quinolones due to higher prevalence of resistant strains 1, 3