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The Medical Letter on Drugs and Therapeutics
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1623
In Brief: New Recommendations for Gonococcal Infection

The CDC has issued new recommendations for treatment of gonococcal infection. A single 500-mg IM dose (1000 mg in patients weighing ≥150 kg) of the third-generation cephalosporin ceftriaxone is now the treatment of choice for patients with uncomplicated urogenital, rectal, or pharyngeal gonorrhea.1

RATIONALE — Previous CDC guidelines had recommended ceftriaxone 250 mg IM plus a single 1000-mg oral dose of the macrolide azithromycin for treatment of uncomplicated gonorrhea.2 Coadministration of azithromycin was recommended to prevent development of ceftriaxone resistance and to treat potential chlamydial co-infection, but continued low resistance rates to ceftriaxone and increasing resistance to azithromycin led to a reevaluation of this guidance. Use of the higher ceftriaxone dose increases the amount of time that free drug levels remain above the minimum inhibitory concentration for Neisseria gonorrhoeae.

TREATMENT CONSIDERATIONS — If IM ceftriaxone is not available, a single 800-mg oral dose of the third-generation cephalosporin cefixime can be used as an alternative, but its efficacy against pharyngeal gonorrhea is limited.

If chlamydial infection has not been excluded, patients treated with a cephalosporin should also take 100 mg of oral doxycycline twice daily for 7 days or, if pregnant, a single 1000-mg dose of oral a zithromycin.

Patients with uncomplicated gonorrhea who have a cephalosporin allergy should receive a 240-mg IM dose of the aminoglycoside gentamicin and a 2000-mg dose of oral azithromycin. High oral doses of azithromycin can cause nausea and vomiting.1

EPT — Expedited Partner Therapy (EPT) with oral cefixime (single 800-mg dose) can be considered for sex partners of the index patient. Doxycycline (100 mg twice daily for 7 days) should be added if chlamydial co-infection has not been excluded.1,3

TEST OF CURE — A test of cure is not needed for patients with uncomplicated urogenital or rectal gonorrhea who are treated with a recommended or alternative regimen; test of cure 7-14 days after treatment is recommended for pharyngeal gonorrhea.1

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