Gonorrhea | Questions & Answers | 2010 Treatment Guidelines

Answer: 

Yes, gonorrhea treatment recommendations for contacts are the same as for the index patient. The most effective treatment for uncomplicated gonorrhea is combination therapy with ceftriaxone 250 mg intramuscularly and either azithromycin 1 gram orally as a single dose or doxycycline 100 mg orally twice daily for seven days. See MMWR’s August 10, 2012 Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections for more information regarding management of sex partners.

Due to concerns about emerging gonococcal resistance to cephalosporins, CDC no longer recommends oral cephalosporins for treatment of gonococcal infections.

Answer: The increased dose of ceftriaxone 250 mg. is now recommended given 1) increasingly wide geographic distribution of isolates demonstrating decreased susceptibility to cephalosporins in vitro; 2) reports of ceftriaxone treatment failures; 3) improved efficacy of ceftriaxone 250 mg. in pharyngeal infection, often unrecognized; and 4) the utility of having a simple and consistent recommendation.

Answer: Dual therapy for gonococcal infections (i.e., with ceftriaxone in a single intramuscular dose, in combination with either azithromycin or doxycycline) is now recommended in the 2010 STD Treatment Guidelines, independent of the patient's chlamydial infection status. N. gonorrhoeae has the potential to develop resistance to the few antimicrobial therapies available. Dual therapy may hinder the development of antimicrobial-resistant organisms. Finally, particularly in men, post-gonococcal urethritis can occur even in the absence of chlamydial infections. For all of these reasons, dual therapy is preferred for all patients with gonorrhea, irrespective of chlamydial test results.

Answer: In the 2010 STD Treatment Guidelines ceftriaxone in a single injection of 250 mg. is now the recommended first-line therapy for uncomplicated gonococcal infection at all anatomic sites. Decreased susceptibility of N. gonorrhoeae to cephalosporins, particularly orally delivered forms, is expected to continue to spread; therefore, clinicians should opt for ceftriaxone as first-line therapy. This treatment also maximizes patient compliance. Ceftriaxone at a dose of 250 mg. given as dual therapy with azithromycin or doxycycline remains the recommended, preferred therapy for all forms of gonorrhea whenever possible. Some patients prefer shots over oral therapy, and even at a dose of 250 mg., ceftriaxone shots given using a small-gauge needle and diluted in lidocaine are not terribly uncomfortable. Dual therapy should be used even if we know the patient doesn't have chlamydia, due to issues of nonchlamydial STD problems such as nonchlamydial, nongonococcal urethritis, which are of concern, in addition to a concern about antibiotic resistance. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

Answer: Dual therapy for gonococcal infections (e.g., treatments including azithromycin or doxycycline) is now recommended in the 2010 STD Treatment Guidelines. Potential benefits of azithromycin use include single-dose administration and absence of tetracycline-class side effects, including photosensitivity and esophageal irritation; additionally, limited data suggest dual therapy with azithromycin may enhance treatment efficacy for pharyngeal infection when oral cephalosporins must be used.

Answer: There is no specific recommendation for coadministering an antiemetic medication when treating with azithromycin 2 g. Most patients tolerate the 2 g. dose; many clinicians indicate that taking azithromycin with even a small amount of food also helps reduce gastrointestinal side effects. For those patients with a history of intolerance to this regimen, or who require retreatment following an episode of intolerance, an antiemetic may be considered.

Answer: Azithromycin is recommended in conjunction with ceftriaxone (or oral cephalosporins if ceftriaxone is not an option), as part of dual therapy for gonorrhea. Single-drug oral therapy with azithromycin 2 g. is effective against uncomplicated gonococcal infection, but concerns about resistance should restrict its use to limited circumstances, such as documented cephalosporin allergy or severe reaction to penicillin (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).

Answer: As of April 2007, based on increasing resistance, fluoroquinolones are no longer recommended in the U.S. for treatment of gonorrhea and associated conditions, such as PID. (2010 STD Treatment Guidelines, page 50) Also see Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections.

Answer: Ceftriaxone in a single injection of 250 mg. is now the recommended first-line therapy in the 2010 STD Treatment Guidelines for uncomplicated gonococcal infection at all anatomic sites (e.g., cervical, urethral, rectal, and pharyngeal). In addition, dual therapy (e.g., including azithromycin or doxycycline) for gonococcal infection at all anatomic sites is now recommended, independent of the patient's CT infection status. (2010 STD Treatment Guidelines, page 50) Also see Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections

Answer: Ceftriaxone in a single injection of 250 mg. is now the recommended first-line therapy in the 2010 STD Treatment Guidelines for uncomplicated gonococcal infection at all anatomic sites. Decreased susceptibility of N. gonorrhoeae to cephalosporins, particularly orally delivered forms, is expected to continue to spread; therefore, clinicians should opt for ceftriaxone as first-line therapy. This treatment also helps to maximize patient compliance. Use oral cephalosporins only when ceftriaxone is not an option. Also, new recommendations are now available for persons with cephalosporin-related treatment failure (see MMWR, July 8, 2011 / 60(26);873-877). Dual therapy (e.g., including azithromycin or doxycycline) for gonococcal infections at all anatomic sites is now recommended, independent of the patient's CT infection status. Also see Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections

Answer: “To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborn infants; this procedure is required by law in most states.” The recommended regimen for this ocular prophylaxis is erythromycin (0.5%) ophthalmic ointment in each eye in a single application (2010 STD Treatment Guidelines, page 55).

Answer: The choice of therapy depends on the nature of the drug allergy. Patients with severe reactions to penicillin (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis) may be treated with azithromycin 2 g. orally, which is effective against uncomplicated gonococcal infection, notwithstanding concerns about decreased susceptibility of N. gonorrhoeae to macrolides. Since reactions to first generation cephalosporins occur in only 5% to 10% of persons with a history of penicillin allergy, and occur less frequently with third-generation cephalosporins, use of ceftriaxone is reasonable in those patients with penicillin reactions that are not severe, as described above.

Answer: Ceftriaxone in a single injection of 250 mg. PLUS azithromycin OR doxycycline is now recommended for gonococcal infection of the pharynx. Gonococcal infections of the pharynx are more difficult to eradicate than infections at urogenital and anorectal sites. Additionally, new recommendations are also available for persons with cephalosporin-related treatment failure (see MMWR, July 8, 2011 / 60(26);873-877).

Answer: In the pregnant patient with multiple documented allergies to penicillins, cephalosporins, and macrolides, treatment of N. gonorrhoeae or chlamydia infection may require desensitization to recommended drug regimens, however infectious disease consultation is recommended.

Answer: Patients with documented allergy to cephalosporins may be treated with azithromycin 2 g. orally, which is effective against uncomplicated gonococcal infection, notwithstanding concerns about decreased susceptibility of N. gonorrhoeae to macrolides (2010 STD Treatment Guidelines, page 51).

Answer: Single-drug treatment for gonorrhea, is no longer considered adequate therapy in the U.S.. Spectinomycin is no longer available in the U.S.. Ceftriaxone in a single injection of 250 mg. PLUS azithromycin OR doxycycline is now recommended treatment for uncomplicated gonococcal infection. As of April 2007, based on increasing resistance, fluoroquinolones are no longer recommended in the U.S. for treatment of gonorrhea and associated conditions, such as PID (see 2010 STD Treatment Guidelines, page 51 for a complete discussion of alternative regimens for gonococcal infections). Also see Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections

Answer: Assuming adequate deltoid muscle mass, ceftriaxone can be administered at this site with a small gauge needle (e.g., 22-gauge or smaller).

Answer: Nongonococcal, nonchlamydial cervicitis is quite common, so it is important to think about what else can cause cervical inflammation (see pg 43 of the 2010 STD Treatment Guidelines for a discussion of the etiology of cervicitis). Consider trichomoniasis, herpes, and even bacterial vaginosis, which can cause cervical inflammation when severe. Evaluate female patients for other factors associated with persistent cervicitis, such as persistent abnormality of vaginal flora, exposure to chemical irritants (such as douching or application of intravaginal products) or idiopathic inflammation in the zone of ectopy. Use of nucleic acid amplification tests (NAATs), which are highly sensitive, will ensure against the possibility of a false negative test. If NAATs continue to be negative, azithromycin is recommended due to its activity against mycoplasma. There is no widely used and recommended diagnostic test for mycoplasma at this point. The addition of a cephalosporin, if you have not detected gonorrhea with a sensitive test, is probably not indicated. If you are in a situation where you still really do not know, and you have tried all the above, then the next step is probably to talk to an infectious disease specialist, a gynecologist, or someone at an STD/HIV Prevention Training Center.