Updated Treatment Recommendations for Gonococcal Infection
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Antimicrobial resistance in bacterial pathogens like Neisseria gonorrhoeae continues to be a threat, and we cannot address this serious public health concern alone. As a result of continued trends in antimicrobial resistance, we are asking health care providers to update their STD management practices to treat uncomplicated gonococcal infection with just one higher dosage (500mg) injection of ceftriaxone. Additionally, if chlamydial infection has not been excluded, persons should be treated for coinfection with oral doxycycline (100 mg twice daily for 7 days). Please review CDCs' December 17, 2020 Morbidity and Mortality Weekly Report for full details and recommended guidance.
We appreciate all that you do to combat STDs including HIV and adult viral hepatitis and even more so as our nation forges a path to recover from the COVID-19 pandemic.
Actions Requested
· Treat uncomplicated gonococcal infection with a single intramuscular dose of 500 mg ceftriaxone.
· For uncomplicated rectal, vaginal, or urethral infections, oral treatment with 800 mg cefixime is an alternative treatment.
· If chlamydia has not been ruled out, treat additionally with doxycycline, 100 mg twice daily for 7 days. If the patient is pregnant, or if adherence to a full week regimen may be an issue, treat with azithromycin 1 g.
· If cephalosporins cannot be used, treat with a single 240 mg dose of gentamycin with 2 g azithromycin.
· Consult an infectious disease specialist for alternative treatment options for treating persons with an anaphylactic or other severe reaction to ceftriaxone, especially for pharyngeal infection, for which there is no highly effective second line therapy.
· Incorporate patient delivered partner therapy (PDPT) into your STD management practices for controlling chlamydial and gonorrheal infections.
o For expedited partner therapy to treat partners of patients who have tested positive for gonorrhea, the recommended dosages are 800 mg cefixime in a single dose and doxycycline, 100 mg twice daily for 7 days. If adherence is an issue, 2 grams of azithromycin in a single dose can be prescribed instead of doxycycline.
o PDPT/EPT is not recommended for partners of patients who are MSM (men who have sex with men). MSM patients and their partners should be offered testing for HIV and syphilis alongside testing and treatment for gonorrhea and chlamydia.
· DO NOT TREAT gonorrhea with 2 grams of azithromycin alone.
· Offer test of cure (TOC) for all gonococcal infections of the pharynx at 7-14 days after treatment.
· Stay up-to-date on the National STD Curriculum at https://www.std.uw.edu/.
Questions: Contact Zandt Bryan 360.890.5816, Katrina Miller 360.236.3425, or Kari Haecker 360.890.6897.
Cases should be reported to your local health department. Reporting information and forms for public health jurisdictions can be found on the DOH website.
Recommendations
Regimen for uncomplicated gonococcal infections of the cervix, urethra, or rectum:
Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb).
• For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
• If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. Azithromycin 1 g as a single dose is still a second line treatment for chlamydia, and is the preferred alternative to doxycycline in pregnant patients.
Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, or rectum if ceftriaxone is not available:
Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose OR
Cefixime 800 mg orally as a single dose. If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.
Recommended regimen for uncomplicated gonococcal infections of the pharynx:
Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb).
· For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
· If chlamydia coinfection is identified when pharyngeal gonorrhea testing is performed, providers should treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.
· No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended.*
· For persons with an anaphylactic or other severe reaction (e.g., Stevens Johnson syndrome) to ceftriaxone, consult an infectious disease specialist for an alternative treatment recommendation.
Abbreviation: IM = intramuscular.
*CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2015;64(No. RR-3). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm.
Resources
· National Network of STD Clinical Prevention Training Centers:
o Resources: https://nnptc.org/resources/
· Washington State Provider Guidelines for Patient Delivered Therapy (PDF)
· Department of Health Expedited Therapy
· Expedited Partner Therapy (CDC)
· Department of Health Statement Regarding STD Management During COVID-19 (April 2020)
· STD Treatment Options (CDC, April 2020); Clarification (CDC, May 2020)
References
St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon