Rapid cure of gonorrhea is critical to curtail transmission. Because of emerging resistance that has resulted in limited choices for antibiotics, it is imperative to follow treatment guidelines to avoid further resistance and to obtain optimal treatment results. For more information, see CDC Sexually Transmitted Diseases Treatment Guidelines, 2015.
Medical therapy requires dual antibiotic treatment with efficacy against N gonorrhoeae. Until several years ago, the treatment of choice involved oral medication for as long as 10 days or an injection; however, patients tend to be poorly compliant with medications for various reasons, and the availability of newer medications has allowed in-office single-doses of ceftriaxone IM plus azithromycin PO treatment to ensure compliance.
After obtaining specimens for diagnosis, many practitioners presumptively treat patients based on history and examination, because of the risk of poor follow-up, complications, and continuing disease spread to other partners. In addition, because gonorrhea is often simultaneously diagnosed with chlamydia , many practitioners treat patients for both diseases when treating for either one beyond the newborn period.
Disseminated or complicated infections (eg, endocarditis, meningitis) require more prolonged, inpatient therapy. For these cases, an infectious disease consultation is essential.
N gonorrhoeae in the United States is not adequately susceptible to penicillins, fluoroquinolones, or erythromycin for these antimicrobials to be recommended.
Ceftriaxone is part of the dual-drug regimen (along with azithromycin) for treating gonorrhea because of the attainment of high, sustained bactericidal levels in the blood. Ceftriaxone binds to penicillin-binding proteins, inhibiting bacterial cell wall growth.
Azithromycin inhibits bacterial growth, possibly by blocking the dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. It is part of the first-line preferred dual-drug regimen for gonococcal infections plus ceftriaxone IM.
Cefixime, a cephalosporin, inhibits bacterial cell wall synthesis by binding to 1 or more of the penicillin-binding proteins. It is not used first-line and it is an alternant therapy for uncomplicated gonorrhea if ceftriaxone is unavailable. For this situation, patients can be given a single oral dose of cefixime 400 mg plus a single dose of azithromycin 1 g PO.
Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline 100 mg PO BID for 10-14 days may be used in addition to a single dose of ceftriaxone 250 mg IM for gonococcal epididymitis or pelvic inflammatory disease.
Erythromycin is the only antibiotic ophthalmic ointment recommended for use in neonates for prophylaxis of gonococcal ophthalmia neonatorum. Silver nitrate and tetracycline ophthalmic ointments are no longer manufactured in the United States, bacitracin is not effective, and povidone iodine has not been studied adequately. Gentamicin ophthalmic ointment has been associated with severe ocular reactions in neonates and should not be used for ocular prophylaxis.
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