Gonorrhea medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2] Nuha Al-Howthi, MD[3]

Overview

The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, Ceftriaxone is standard of care for treatment of gonorrhea. Routinely combining ceftriaxone with azithromycin for treatment of gonorrhea is no longer recommended.

Medical Therapy

• The mainstay of therapy for gonococcal infections is antimicrobial therapy.

Type of gonococcal infection	Regimen
Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea	Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb) ceftriaxone 1 g IM, for persons weighing ≥150 kg (300 lb). Chlamydial co-infection: add doxycycline 100 mg PO BID 7 days. (In pregnancy azithromycin 1 g as a single dose)
Uncomplicated Alternative regimen	Gentamicin 240 mg IM as a single dose plus azithromycin 2 g PO as a single dose OR Cefixime 800 mg PO as a single dose. (Add doxycycline 100 mg PO BID for 7 days if chlamydial infection has not been excluded) (During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia).
Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available	Ceftriaxone is not available: A different injectable cephalosporin like ceftizoxime [500 mg IM], cefoxitin [2 g IM with probenecid 1 g PO], or cefotaxime [500 mg IM]) can be used. cefixime 800 mg PO OD if the other injectable cephalosporin not available. Severe Cephalosporin allergy Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose (alternative) Test of cure should be performed after 1 week
Arthritis and arthritis-dermatitis syndrome	Ceftriaxone 1 g IM/IV q24h for 7 days Cefotaxime 1 g IV q8h for 7 days (alternative) Ceftizoxime 1 g IV q8h for 7 days
Gonococcal meningitis and endocarditis	Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days

Antimicrobial Regimen

• Neisseria gonorrhoeae treatment

• 1. Gonococcal infections in adolescents and adults

• 1.1 Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.

• Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
• ceftriaxone 1 g IM, for persons weighing ≥150 kg (300 lb).
• Chlamydial co-infection:
  • add doxycycline 100 mg PO BID 7 days. (In pregnancy azithromycin 1 g as a single dose)

• 1.2 Uncomplicated gonococcal infections of the pharynx

• pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
• Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
• ceftriaxone 1 g IM, for persons weighing ≥150 kg (300 lb).
• Chlamydial co-infection:
  • add doxycycline 100 mg PO BID 7 days. (In pregnancy azithromycin 1 g as a single dose)
  • No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended

• 1.2.1 Management of sex partners

• Expedited partner therapy: oral cefixime 800 mg orally once plus treatment for chlamydia is used for treatment of the partner.
• Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
• Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
• Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
• Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.

• 1.2.2 Allergy, intolerance, and adverse reactions

• Ceftriaxone is not available:
  • A different injectable cephalosporin like ceftizoxime [500 mg IM], cefoxitin [2 g IM with probenecid 1 g PO], or cefotaxime [500 mg IM]) can be used.
  • cefixime 800 mg orally once can be used for gonococcal therapy if the other injectable cephalosporin not available.
• Severe Cephalosporin allergy:
  • Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
  • Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose (alternative)
• Note: Use of Ceftriaxone or Cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).

• 1.2.3 Pregnancy
  • Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
  • Chlamydia coinfection should be treated with azithromycin instead of doxycycline.
    
• 1.2.4 Suspected cephalosporin treatment failure

• Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
• Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
• Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with Cefixime and Azithromycin)
• Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.

• 1.3 Gonococcal conjunctivitis

• Preferred regimen: a single 1 g IM dose of ceftriaxone.

Note: A topical fluoroquinolone, saline irrigation are also recommended.

• 1.3.1 Management of sex partners

• Patients should be instructed to refer their sex partners for evaluation and treatment.

• 1.4 Disseminated gonococcal infection

• 1.4.1 Arthritis and arthritis-dermatitis syndrome

• Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days.
• Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
• Alternative regimen (2): Ceftizoxime 1 g IV q8h for 7 days.
• Note: Once clinical improvement with ceftriaxone is noted for 24 to 48 hours, the regimen can be completed with intramuscular ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.

• 1.4.2 Gonococcal meningitis and endocarditis

• Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days

• 2. Gonococcal infections among neonates

• 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae

• Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
• Recommended Regimen for prevention Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth

• 2.1.1 Management of mothers and their sex partners

• Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates

• Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV q24h for 7 days
• Preferred regimen (2): Cefotaxime 25 mg/kg IM/IV q12h for 7 days.
• Note (1): The duration of treatment is 10-14 days if meningitis is documented.
• Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.

• 2.2.1 Management of mothers and their sex partners

• Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).

• 2.3 Neonates born to mothers who have gonococcal infection

• Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)

• 2.3.1 Management of mothers and their sex partners

• Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.

• 3. Gonococcal infections among infants and children

• 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

• Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)

• 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

• Preferred regimen: Ceftriaxone 500 mg IM in a single dose.
• Alternative regimen: Gentamicin 240 mg IM in a single dose PLUS Azithromycin 2 g PO in a single dose OR Cefixime 800 mg PO in a single dose

• 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)

• 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis

• Preferred regimen: Ceftriaxone 1 g IM or IV q24h for 7 days.

Follow-Up

A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or NAAT. If the NAAT is positive, effort should be made to perform a confirmatory culture before commencing retreatment.

• All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing
• Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
• If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

References

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