ACOG Advocates Dual Therapy for Gonococcal Infections

Diana Swift

October 22, 2015

The American College of Obstetricians and Gynecologists (ACOG) recommends dual antibiotic therapy for gonococcal infections, according to a committee opinion published in the November issue of Obstetrics & Gynecology.

Ceftriaxone and azithromycin should be used as first-line treatment, as Neisseria gonorrhoeae has developed resistance to the sulfonamides, the tetracyclines, and penicillin, the authors note.

Gonorrhea is the second most commonly reported bacterial sexually transmitted infection in the United States, with an estimated 820,000 new cases occurring each year. In 2007, the emergence of fluoroquinolone-resistant N gonorrhoeae prompted the Centers for Disease Control and Prevention to cease recommending fluoroquinolones for gonorrhea, leaving cephalosporins as the only remaining class of recommended antimicrobials.

"Antimicrobial resistance limits treatment success, heightens the risk of complications, and may facilitate the transmission of sexually transmitted infections," the committee members write.

ACOG advises that ceftriaxone and azithromycin be administered together on the same day, preferably simultaneously, and under direct observation. The preferred first-line regimen for uncomplicated gonococcal infections of the cervix, urethra, and rectum is ceftriaxone, 250 mg, in a single intramuscular dose plus azithromycin, 1 g, in a single oral dose. Second-line regimens include oral cefixime plus oral azithromycin and, in cases of severe penicillin allergy, oral gemifloxacin plus azithromycin or gentamicin (intramuscularly) plus azithromycin.

Infected pregnant women should also receive dual therapy and do not require a test of cure. They should be retested in the third trimester unless they have been recently treated.

A test of cure also is not needed for individuals diagnosed with uncomplicated urogenital or rectal gonorrhea who are treated with the recommended first-line or second-line regimens.

Repeat infection is prevalent among patients treated in the preceding several months, so patients should be retested 3 months after treatment. "For patients who get retested and receive positive test results, most are more likely to be from reinfection than from treatment failure," the authors write.

Among the committee's other recommendations are that:

  • "Women with pharyngeal gonorrhea treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or nucleic acid amplification test."

  • "Recent sex partners within 60 days of a patient's diagnosis should seek evaluation and presumptive treatment for N gonorrhoeae and Chlamydia trachomatis infections."

  • "Patients and sex partners should abstain from sexual activity for 7 days after treatment and until sex partners are adequately treated."

Because the Centers for Disease Control and Prevention's guidance on the treatment of gonococcal infections is expected to evolve with scientific and clinical advances, the ACOG committee advises obstetricians and gynecologists to stay current on new developments by visiting the centers' website or contacting state health departments.

Obstet Gynecol. 2015;126:1126. Abstract

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