Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
cephalosporin monotherapy or gentamicin plus azithromycin or ciprofloxacin monotherapy
It is recommended that adult patients with a suspected or confirmed diagnosis of gonorrhea be treated with a single dose of ceftriaxone.[23] One meta-analysis found that ceftriaxone had better efficacy for uncomplicated gonorrhea compared with other antibiotics.[69]
A single dose of oral cefixime is a suitable alternative regimen if ceftriaxone is not available.[23] However, cefixime has a lower response rate and reduced susceptibility compared with ceftriaxone when used for nongenital sites.[23]
In patients with urogenital or anorectal gonorrhea who have a cephalosporin allergy, one option is a single dose of intramuscular gentamicin plus oral azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of this regimen.[23] In an asymptomatic person, a single dose of ciprofloxacin could be used if the provider is able to perform gyrase A (gyrA) testing to identify ciprofloxacin susceptibility (wild type).[23][70] An infectious disease specialist should be consulted for advice on management if there is known penicillin/cephalosporin allergy.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system (CNS) effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[71] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Pharyngeal infections are more difficult to treat than urogenital or anorectal infections. Cefixime has limited efficacy against pharyngeal gonorrhea, and no reliable alternative treatments are available. An infectious disease specialist should be consulted for an alternative treatment recommendation if there is an anaphylactic reaction to ceftriaxone.[23] The Centers for Disease Control and Prevention recommends a test-of-cure 7-14 days after treatment regardless of the treatment regimen used for pharyngeal infections.[23] Use of an antiseptic mouthwash may help with clearance of pharyngeal infections.[72] In people previously treated for gonorrhea, reinfection within 12 months ranges from 7% to 12%, and so they should be retested 3 months after treatment regardless of whether they believe their sex partners were treated.[73][74] If retesting at 3 months is not possible, retesting should be performed within 12 months of initial treatment.[23]
The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission.[23]
[ 
]
In some US states the law permits expedited partner therapy, which is the practice of treating the sex partners of persons with sexually transmitted infections without an intervening medical evaluation or professional prevention counseling.
CDC: expedited partner therapy
Opens in new window[68] This approach should be considered for heterosexual patients with gonorrhea if it cannot be ensured that all of a patient's sex partners from the prior 60 days will be evaluated and treated.
Primary options
ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose
Secondary options
gentamicin: 240 mg intramuscularly as a single dose
and
azithromycin: 2 g orally as a single dose
OR
ciprofloxacin: 500 mg orally as a single dose
OR
cefixime: 800 mg orally as a single dose
cephalosporin monotherapy
A single dose of intramuscular ceftriaxone is recommended as a first-line regimen in pregnant women, preferably given under direct observation.[23]
Consultation with an infectious disease specialist is recommended if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with this regimen.
Pharyngeal infections are more difficult to treat than urogenital or anorectal infections. The Centers for Disease Control and Prevention recommends a test-of-cure 7-14 days after treatment regardless of the treatment regimen used for pharyngeal infections.[23]
The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission.[23]
[ ]
In some US states the law permits expedited partner therapy, which is the practice of treating the sex partners of persons with sexually transmitted infections without an intervening medical evaluation or professional prevention counseling.
CDC: expedited partner therapy
Opens in new window[68] This approach should be considered for heterosexual patients with gonorrhea if it cannot be ensured that all of a patient's sex partners from the prior 60 days will be evaluated and treated.
Primary options
ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose
hospitalization and management by an experienced provider
Pregnant women with complicated infection (i.e., pelvic inflammatory disease, conjunctivitis, or disseminated gonococcal infection) require hospitalization and specialist management from an experienced provider.
The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission.[23]
[ ]
In some US states the law permits expedited partner therapy, which is the practice of treating the sex partners of persons with sexually transmitted infections without an intervening medical evaluation or professional prevention counseling.
CDC: expedited partner therapy
Opens in new window[68] This approach should be considered for heterosexual patients with gonorrhea if it cannot be ensured that all of a patient's sex partners from the prior 60 days will be evaluated and treated.
repeat investigations and retreatment + report to health department
Persistent infection after treatment may be due to reinfection or resistance/treatment failure. Reinfection is a likely possibility, and partner treatment should be reinforced.[23]
Patients who have persistent symptoms after treatment should be retested by culture (preferably with simultaneous nucleic acid amplification test). If these cultures are positive for gonococcus, isolates should be submitted for resistance testing.
Persistent gonorrhea infections should be retreated with a single dose of intramuscular ceftriaxone, and an infectious disease specialist should be consulted.[23]
A single-dose of intramuscular gentamicin plus oral azithromycin can be used as an alternative regimen for urogenital and rectal gonorrhea, particularly if resistance to cephalosporins is suspected.[23] High-dose oral azithromycin is commonly accompanied by nausea and vomiting in patients. No reliable alternative treatments are available for pharyngeal gonorrhea.[23]
Patients with treatment failure after receiving an alternative regimen (cefixime or gentamicin plus azithromycin) should be retreated with a single dose of ceftriaxone, with or without doxycycline if chlamydial infection has not been excluded.[23]
A test-of-cure should be done 7 to 14 days after retreatment.
Treatment failures should be reported to the Centers for Disease Control and Prevention through the local or state health department within 24 hours of diagnosis.[23]
The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission.[23]
[ ]
In some US states the law permits expedited partner therapy, which is the practice of treating the sex partners of persons with sexually transmitted infections without an intervening medical evaluation or professional prevention counseling.
CDC: expedited partner therapy
Opens in new window[68] This approach should be considered for heterosexual patients with gonorrhea if it cannot be ensured that all of a patient's sex partners from the prior 60 days will be evaluated and treated.
Primary options
ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose
Secondary options
gentamicin: 240 mg intramuscularly as a single dose
and
azithromycin: 2 g orally as a single dose
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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