What is the first-line pharmacologic treatment for uncomplicated gonococcal infection?

Updated: Sep 07, 2018
  • Author: Brian Wong, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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First-line dual drug therapy regimen is as follows [1] :

  • Ceftriaxone 250 mg intramuscular (IM) single dose plus
  • Azithromycin 1 g PO single dose

The 250-mg IM dose of ceftriaxone is now recommended over the 125-mg dose, given concern for resistance, prior lower-dose ceftriaxone dose failures, and seemingly improved efficacy in pharyngeal infections. No benefit has been found for ceftriaxone dosing greater than 250 mg. Ceftriaxone is safe and effective in pregnant women and probably destroys incubating syphilis. Its major drawback is the necessity for IM administration.

A review of the recommendations for antimicrobial treatment of uncomplicated gonorrhea in 11 East European countries showed ceftriaxone (250-1000 mg IM once) was a first-line antimicrobial in all of them. [57] (However, many of the second-line and alternative treatments were less than ideal, with regionally manufactured antimicrobials predominantly used.)

Data have indicated that the 400-mg oral dose of cefixime does not provide a bactericidal level that is as high or as sustained as that of the 250-mg dose of ceftriaxone and provided a lower cure rate for pharyngeal gonorrhea. The oral cephalosporins cefpodoxime and cefuroxime seem to be inferior and have less desirable pharmacodynamics. [58, 59] In addition, based on findings from the Gonococcal Isolate Surveillance Project (GISP), reported July 2011, from 2009-2010 a decreasing susceptibility to cefixime was found. [60] In response, the CDC issued revised guidelines that do not include oral cephalosporins as first-line treatment. [61]

Because of the persistent increase in multidrug-resistant gonorrhea, the 2015 CDC treatment recommendations are as follows [1] :

  • Treat gonorrhea at any anatomic site with a single intramuscular injection of 250 mg ceftriaxone plus azithromycin 1 g PO as a single dose
  • If ceftriaxone is unavailable, patients can be given a single oral dose of cefixime 400 mg plus a single dose of azithromycin 1 g PO

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