Medication

Historically the treatment of choice for gonorrhea has been oral medication for up
to 10 days or an injection. Newer medications allowing in-office/in-ED, directly
observed, single-dose oral treatment overcome poor patient compliance. In
addition, because gonorrhea is often diagnosed simultaneously with chlamydia,
the clinician should treat for both upon diagnosis of either when treating for either
beyond the newborn period. Partner diagnosis and treatment is important to
prevent reinfection and complications.

In April 2007, the Centers for Disease Control and Prevention (CDC) updated
treatment guidelines for gonococcal infection and associated conditions.
Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the
United States. The recommendation was based on analysis of new data from the
CDCs Gonococcal Isolate Surveillance Project (GISP). The data from GISP
showed the proportion of gonorrhea cases in heterosexual men that were
fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6%
in 2001. The data were published in the April 13, 2007, issue of the Morbidity and
Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the
cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose).
Fluoroquinolones may be an alternative treatment option for disseminated
gonococcal infection if antimicrobial susceptibility can be documented.[2 ]

For more information see, the CDCs Antibiotic-Resistant Gonorrhea Web site;
CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape
Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefixime (Suprax)

The DOC because of oral efficacy, single-dose treatment, and lower cost than
parenteral medication. Cefixime inhibits bacterial cell wall synthesis by binding to
one or more of the PBPs. After a period of unavailability, oral cefixime is now
available again in the United States, in tablet and suspension, for the treatment of
uncomplicated urogenital or rectal gonorrhea.[5 ]
Dosing
Adult
400 mg PO once for uncomplicated genitourinary or rectal infection
Pediatric
<45 kg: 8 mg/kg PO once; not to exceed 400 mg
>45 kg: Administer as in adults
Interactions
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may
increase effects of cefixime
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some
studies in animals
Precautions
Not effective against pharyngeal gonococcal infection and not recommended for
PID
Adverse effects, including diarrhea, abdominal pain, nausea, and rashes, occur
more commonly with prolonged courses of therapy; single-dose treatment is
unlikely to cause ongoing problems
Caution in documented hypersensitivity to penicillins or reduced renal function
Administer with food to minimize GI adverse effects
Adjust dose in renal impairment

Ceftriaxone (Rocephin)

DOC for DGI, outpatient PID, and pharyngeal infection. Secondary DOC for
uncomplicated genitourinary infections, but only because of higher cost,
discomfort, and additional administration expense of injection.
Ceftriaxone binds to PBPs inhibiting bacterial cell wall growth.
Dosing
Adult
125-250 mg IM once; 125 mg if uncomplicated genitourinary, rectal, or
pharyngeal infection; 250 mg for PID
1 g IV/IM q24h for DGI
1-2 g IV q12h for gonococcal meningitis or endocarditis
1 g IM once for gonococcal conjunctivitis; consider single saline lavage as well
Pediatric
25-50 mg/kg IV/IM as single dose for conjunctival infection (maximum 125 mg)
25-50 mg/kg/d IV/IM for 7 d for scalp abscess, sepsis, arthritis
25-50 mg/kg/d IV/IM for 10-14 d for suspected or known meningitis
125 mg IM once for children <45 kg with uncomplicated urethritis, cervicitis,
pharyngitis, or rectal infection
>45 kg: Administer as in adults
Interactions
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic
acid, furosemide, and aminoglycosides may increase nephrotoxicity
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some
studies in animals
Precautions
Local site reactions (redness, pain) in 10-17% of adults (using 1% lidocaine as a
diluent may reduce discomfort); caution with history of penicillin allergy or
gallbladder, biliary tract, and hepatic disease; nephrotoxicity, similar to
cephalosporins, is possible cause of pseudomembranous colitis; adjust dose in
renal impairment; caution in breastfeeding women and in those with allergy to
penicillin

Spectinomycin (Trobicin)
Indicated for patients with beta-lactam intolerance, but second-line choice due to
poor efficacy in pharyngitis.
Dosing
Adult
2 g IM once
Pediatric
40 mg/kg IM once
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some
studies in animals
Precautions
Benzyl alcohol used as a diluent associated with fatal gasping syndrome in
infants; antibiotics may mask or delay symptoms of incubating syphilis; perform a
serologic test for syphilis in all patients with gonorrhea at time of diagnosis
followed by additional test after 3 months; monitor clinical effectiveness to detect
resistance by N gonorrhoeae
Silver nitrate
Inhibit growth of both gram-positive and gram-negative bacteria. Germicidal
effects are attributed to precipitation of bacterial proteins by liberated silver ions.
Dosing
Adult
Not used for this indication
Pediatric
2 gtt OU into conjunctival sac once immediately after birth (no later than 1 h after
delivery)
Interactions
Decreases effects of sulfacetamide preparations
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in
humans; may use if benefits outweigh risk to fetus
Precautions
Repeated application into eye can cause cauterization of cornea and blindness

Erythromycin ophthalmic (Erygel)

Indicated for infections caused by susceptible strains of microorganisms and for
prevention of corneal and conjunctival infections.
Dosing
Adult
Not used for this indication
Pediatric
Apply 0.5-inch (1.25 cm) ribbon OU into conjunctival sac once immediately after
birth (no later than 1 h after delivery)
Interactions
None reported
Contraindications
Documented hypersensitivity; viral, mycobacterial, or fungal infections of eye;
patients using steroid combinations after uncomplicated removal of a foreign body
from cornea should avoid using this product
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some
studies in animals
Precautions
Do not use topical antibiotics to treat ocular infections that may become systemic;
prolonged or repeated antibiotic therapy may result in bacterial or fungal
overgrowth of nonsusceptible organisms and may lead to a secondary infection
(take appropriate measures if superinfection occurs)