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Chapter 147: Gonorrhea

Lindsay C. Strowd

GONORRHEA

Therapeutic Approach

Gonorrhea is a sexually transmitted bacterial infection by Neisseria gonorrhoeae, a gram-negative intracellular bacteria visualized as pairs of cocci. Gonorrhea can be horizontally transmitted through oral, vaginal, and anal intercourse as well as vertically transmitted from mother to baby through an infected vaginal canal. Gonorrheal infections can often coexist with chlamydial infections so all patients with suspected gonorrhea should also be tested or empirically treated for chlamydia. Patients who have gonorrhea should abstain from sexual activity for 7 days after treatment. All sex partners should also be treated, including any sexual contact within the past 14 days for diagnosis. The Centers for Disease Control (CDC) have published recommended treatment guidelines and updated these guidelines in 2021 to reflect current trends in antimicrobial resistance. Treatment recommendations vary based on type of infection and age of patient. See Table 147-1.

Table 147-1Gonorrhea Treatment Table
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Table 147-1 Gonorrhea Treatment Table
MEDICATION NAME INDICATIONc MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE) OTHER
Adult and Adolescent Therapy       
Ceftriaxonea UUG, URG, UPG, EPT Cephalosporin, third-generation

500 mg single IM dose (wt <150 kg)

1000 mg single IM dose (wt >150 kg)

 Injection site reaction, diarrhea

None

Use with caution in patients with PCN allergy

 Ib1-7  
  GC   1000 mg single IM dose     Ia1-7 Consider saline eye lavage as one-time adjunctive treatment
  GRA, ADS   1000 mg IM or IV q24h for 7 d     1b1-7  
  GM/GE   1000-2000 mg IV q24h × 10-14 d for GM, >4 wk for GE     1b1-7  
Gentamicin + Azithromycinb UUG, URG Aminoglycoside + macrolide 240 mg single IM dose gent + 2 g single PO dose azithro Vomiting and GI distress None 1b1,5,8-11

To be used if patient has cephalosporin allergy

Avoid gentamicin use during pregnancy
Cefiximeb UUG, URG, EPT Cephalosporin, third-generation 800 mg single PO dose Diarrhea, abdominal pain None Ib1,4,10 Limited efficacy for UPG
Cefotaxime GRA, ADS Cephalosporin, third-generation 1000 mg IV q8h for 7 d Diarrhea, abdominal pain None 1B1,10  
Ceftizoxime GRA, ADS Cephalosporin, third-generation 1,000 mg IV q8h for 7 d Diarrhea, abdominal pain None Ib1,10  
Neonatal Treatment       
Erythromycin GON prophylaxis Macrolide 0.5% ophthalmic ointment in each eye, single application at birth   None Ib1,12  
Ceftriaxonea GON Cephalosporin, third-generation 25-50 mg/kg IV or IM single dose, not to exceed 250 mg Injection site reaction, diarrhea

Cannot be administered if neonate is receiving IV calcium

Caution with concurrent hyperbilirubinemia

 Ib1,7  
  DGI   25-50 mg/kg IV or IM ×7 d, or ×10-14 d if meningitis     Ib1,7  
  G ...

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