Management of Gonorrhea

Primary Treatment Regimen

The Centers for Disease Control and Prevention recommends ceftriaxone 500 mg intramuscularly as a single dose, plus concurrent treatment for presumptive chlamydial coinfection with doxycycline, for the treatment of uncomplicated gonorrhea in patients with a high prevalence of chlamydial coinfection (40-50% of gonorrhea patients) 1
The higher 500 mg dose of ceftriaxone is particularly important for pharyngeal infections, where extended-spectrum cephalosporins have marked variability in clearance and half-life within pharyngeal tissues, with a cure rate of 100% for urogenital gonorrhea and 90% for pharyngeal gonorrhea 1

The American College of Obstetricians and Gynecologists recommends cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose, with mandatory test-of-cure at 1 week, as an alternative regimen for patients who cannot receive ceftriaxone 2, 1
The Infectious Diseases Society of America recommends azithromycin 2 g orally as a single dose, with mandatory test-of-cure at 1 week, for patients with severe cephalosporin allergy, although this regimen has lower efficacy (93% cure rate) and causes significant gastrointestinal side effects 2, 3

The Centers for Disease Control and Prevention recommends ceftriaxone 500 mg intramuscularly PLUS azithromycin 1 g orally (single dose) for pregnant women, as quinolones, tetracyclines, and doxycycline are contraindicated in pregnancy 1, 2, 4
The American College of Physicians recommends ceftriaxone-based regimens for men who have sex with men (MSM), as quinolones are not recommended due to higher prevalence of resistant strains 6, 1, 7

The Centers for Disease Control and Prevention recommends that patients treated with recommended first-line regimens (ceftriaxone 500 mg) do NOT need routine test-of-cure, but patients treated with cefixime-based regimens or azithromycin 2 g monotherapy should have mandatory test-of-cure at 1 week 5, 4, 6, 2, 1
The Infectious Diseases Society of America recommends retesting for reinfection 3 months after treatment, as most post-treatment infections result from reinfection rather than treatment failure 6, 5, 4

The Centers for Disease Control and Prevention recommends that all sex partners from the preceding 60 days must be evaluated and treated for both gonorrhea and chlamydia, with the same dual therapy regimen as the patient 2, 5, 4, 6, 1
The American College of Physicians recommends expedited partner therapy (EPT) using oral combination therapy (cefixime 400 mg plus azithromycin 1 g) if partners cannot be linked to timely evaluation, although EPT is NOT recommended for MSM due to high risk of undiagnosed coexisting STDs or HIV 2, 6, 1

The Centers for Disease Control and Prevention recommends screening for syphilis with serology and HIV at the time of gonorrhea diagnosis, as gonorrhea facilitates HIV transmission 1, 5

The Infectious Diseases Society of America recommends never using fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) due to widespread resistance, azithromycin 1 g alone due to insufficient efficacy (only 93% cure rate), and spectinomycin for pharyngeal infections due to low efficacy (only 52% effective for pharyngeal gonorrhea) 6, 1, 8, 5, 4