How Gonorrhea Is Treated

There was a time when all you needed to treat gonorrhea was a shot of penicillin. Sadly, those days are gone. Due to the ongoing high rates of infection (and reinfection), gonorrhea has become resistant to nearly every major antibiotic in the treatment arsenal—and we are down to only a handful of drugs able to treat this otherwise uncomplicated concern.

 Today, the Centers for Disease Control and Prevention (CDC) recommends only two drugs, used in combination, as a first-line therapy—ceftriaxone and azithromycin. A few alternatives are only used in special situations.

The speed at which gonorrhea drug resistance has developed has been nothing short of astonishing. The first major sign of this was in the 1980s when penicillin no longer proved effective in clearing the infection. Prior to 2012, the use oral antibiotics in monotherapy was widespread, the practice of which contributed to the development of resistance as people failed to complete their treatment and passed the increasingly resistant bacteria to others. 

Today, the goal of treatment is to hit the infection hard and fast—ideally with a single dose—so that the bacteria is fully eradicated and not given the opportunity to mutate.

Ceftriaxone and azithromycin, when used in combination, have proven to be drugs able to do this in most (but not all) types of gonorrhea infection.

Uncomplicated Gonorrhea

Uncomplicated gonorrhea of the cervix, rectum, urethra, throat, and eye (gonococcal conjunctivitis) can usually be treated with a single dose of ceftriaxone and azithromycin. For these cases, ceftriaxone is always given intramuscularly (with an injection into a muscle), while azithromycin is delivered orally (in pill form).

Alternative antibiotics may be used, but only if a preferred drug is not available or there is a known drug allergy.

ConditionRecommendation
Cervix, rectum, urethra, or throatCeftriaxone 250mg intramuscularly, plus azithromycin 1g orally in a single dose
If ceftriaxone is not availableCefixime 400mg orally, plus azithromycin 1g orally in a single dose
For people allergic to ceftriaxoneGemifloxacin 320mg orally, plus azithromycin 2g orally for two consecutive days
OR
Gentamicin 240mg intramuscularly, plus azithromycin 2g orally for two consecutive days
For people allergic to azithromycinOne dose of ceftriaxone 250mg intramuscularly, plus doxycycline 200mg orally for seven consecutive days
Gonococcal conjunctivitisCeftriaxone 1g intramuscularly, plus azithromycin 1g orally in a single dose

In addition to being treated, your sex partners also need to contacted, tested, and offered treatment if needed. This is to protect not only their health, but others' (including, potentially, yours).

After treatment is completed, a test to confirm the clearing of the infection is not needed. The only exception is pharyngeal gonorrhea, which is far more difficult to treat.

With that being said, anyone treated for gonorrhea would be asked to have another test done in three months.

This is because the rate of gonorrheal reinfection is high, oftentimes from the same source. Whether your sex partners have been treated or not, it is important to have follow-up testing performed.

Disseminated Gonorrhea

Disseminated gonococcal infection (DGI) is a serious complication caused by an untreated disease. It is often referred to as arthritis-dermatitis syndrome, as the spread of bacteria through the bloodstream can trigger the development of arthritis and skin lesions.

In rare cases, meningitis (inflammation of the membrane surrounding the brain and spinal cord) and endocarditis (inflammation of the heart valves) can develop.

If you are diagnosed with DGI, you would need to be hospitalized so that certain medications can be delivered intravenously (into a vein). The treatment duration would be determined by the type of infection involved.

ConditionRecommendationDuration

Gonococcal
arthritis-dermatitis
(preferred)

Ceftriaxone 1g intravenously every 24 hours, plus a single dose of azithromycin 1g orallyNo less than seven days
Gonococcal
arthritis-dermatitis (alternative)
Cefotaxime 1g intravenously every eight hours, plus a single dose of azithromycin 1g orallyNo less than seven days
Gonococcal meningitisCeftriaxone 1g to 2 g intravenously every 12 to 24 hours, plus a single dose of azithromycin 1g orally10 to 14 days
Gonococcal endocarditisCeftriaxone 1g to 2g intravenously every 12 to 24 hours, plus a single dose of azithromycin 1g orallyUp to four weeks

Other Types

While ceftriaxone and azithromycin are helpful for the above cases, not every infection can be treated with these drugs either exclusively or alone. Among them:

  • Pharyngeal (throat) gonorrhea is much harder to treat. A repeat test 14 days after initial treatment is complete is necessary to determine if the infection has cleared. Based on the results of the tests, additional treatments and follow-ups may or may not be required.
  • Disseminated gonococcal infection (DGI) is caused when the infection spreads through the bloodstream to infect other organs. This usually requires hospitalization and extensive therapy.
  • Neonatal gonorrhea, in which gonorrhea is passed to a baby during pregnancy, can be prevented by treating the mother. If the newborn develops symptoms, treatment would be prescribed based on the baby's weight and specific disease complications.

In Pregnancy and Newborns

If you are diagnosed with gonorrhea during pregnancy, it is important to seek treatment as soon as possible to prevent passing the infection to your unborn baby. The treatment is no different than that of non-pregnant women and of no harm to your baby.

Whether you have been treated for gonorrhea or not, an antibiotic ointment (erythromycin 0.5%) will be applied to the baby's eyes at birth to prevent ophthalmia neonatorum, a gonorrheal eye infection transmitted to the baby as it passes through the birth canal. The ointment is routinely given to all newborns as a precautionary measure.

On the other hand, if you have not been treated or were diagnosed late, your baby will be given additional antibiotics whether there are symptoms or not. Doing so may clear the infection and prevent such complication as vaginitis, urethritis, respiratory infections, and DGI.

The treatment will be directed by the disease complications and the weight of the newborn in kilograms.

ConditionRecommendation
No symptomsCeftriaxone 25mg to 50 mg per kg delivered either intramuscularly or intravenously in a single dose
Gonococcal conjunctivitisCeftriaxone 25mg to 50mg per kg delivered either intramuscularly or intravenously in a single dose
DGI without meningitisCeftriaxone 25mg to 50mg per kg delivered either intramuscularly or intravenously for seven days
OR
Cefotaxime 25mg per kg delivered either intramuscularly or intravenously every 12 hours for seven days
DGI with meningitisCeftriaxone 25mg to 50mg per kg delivered either intramuscularly or intravenously for 10 to 14 days
OR
Cefotaxime 25mg per kg delivered either intramuscularly or intravenously every 12 hours for 10 to 14 days

Sources:

Centers for Disease Control and Prevention. "2015 Sexually Transmitted Diseases Treatment Guidelines: Gonorrhea Infections." Atlanta, Georgia; issued June 4, 2015; updated January 4, 2018.

CDC. "Latest data on Antibiotic-Resistant Gonorrhea." June 14, 2016.

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