What are the CDC guidelines for pharmacologic treatment of gonorrhea?

Updated: Jun 15, 2021
  • Author: Shahab Qureshi, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Per CDC guidelines, single-dose injectable cephalosporin regimens (other than ceftriaxone 250 mg IM) that are safe and generally effective against uncomplicated urogenital and anorectal gonococcal infections include ceftizoxime (500 mg IM), cefoxitin (2 g IM with probenecid 1 g PO), and cefotaxime (500 mg IM). [64] None of the above regimens offers any additional benefits for urogenital infection and may be more questionable in the treatment of pharyngeal infection. [58, 63]

In patients who are cephalosporin allergic, consider alternant dual therapy with single doses of gemifloxacin PO 320 mg plus azithromycin 2 g PO, or gentamicin 240 mg IM plus azithromycin 2 g PO. [64] Note that, while both of the above regimens seemed to have treated the few extragenital infections in the population studied, it was not powered to give reliable estimates of regimen efficacy. Be aware of treatment-limiting adverse gastrointestinal adverse effects (eg, vomiting) of both of the cephalosporin-allergic regimens, 7.7% and 3.3%, respectively.

Another alternative regimen for patients intolerant of cephalosporins include is spectinomycin (2 g IM). Spectinomycin may be costly and is currently unavailable in the United States.

If azithromycin allergic, doxycycline (100 mg PO BID for 7 days) can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime. However, be aware of the rising prevalence of tetracycline resistance among GISP isolates.

The CDC recommends that patients should return for a test of cure in 1 week. The CDC advises that clinicians should perform susceptibility testing in patients who fail to respond to treatment and notify their local public health STD program. [61]

Monotherapy with azithromycin is no longer recommended because of concerns over the ease with which N gonorrhoeae can develop resistance to macrolides, and because several studies have documented azithromycin treatment failures. Strains of N gonorrhoeae circulating in the United States are not adequately susceptible to penicillins, tetracyclines, or older macrolides (eg, erythromycin); thus, use of these antimicrobials cannot be recommended. [1]

Gonococcal pharyngeal infections may be more challenging to eradicate than infections involving urogenital and anorectal areas. [62]

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