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California Gonorrhea Treatment Guidelines  ---  Suspected Gonorrhea Treatment Failure

New handout for Providers:  Gonorrhea Treatment and Management of Suspected Treatment Failure

Gonorrhea Treatment Recommendations

1.      Dual antibiotic treatment with ceftriaxone 250 mg by intramuscular (IM) injection plus azithromycin 1 g orally is the recommended treatment regimen for uncomplicated anogenital and pharyngeal gonorrhea.

2.      Dual antibiotic treatment is recommended even if the concurrent chlamydia test result is negative. 

3.      Dual treatment with ceftriaxone and azithromycin should be given concurrently (on the same day), even if azithromycin was given within the past week for cervicitis or urethritis. 

4.      Cefixime 400 mg orally plus azithromycin 1 g orally may be used as an alternative regimen for anogenital gonorrhea if ceftriaxone is not available. Pharyngeal gonorrhea should be treated with ceftriaxone plus azithromycin (see #1)

5.      Azithromycin 2 g orally in a single dose can be used in patients with severe cephalosporin or penicillin allergy.  Azithromycin monotherapy should be used with caution due to gastrointestinal intolerance and concerns about emerging resistance.


Recommendations for Performing Tests-of-Cure (TOC)

  A test of cure (TOC) with culture 1 week after treatment is recommended for:

        All pregnant women

        Cases of suspected treatment failure

        Patients treated with antibiotic regimens that are not recommended (e.g., fluoroquinolones)

        Men who have sex with men who have been treated with alternative regimens (i.e., cefixime plus azithromycin or doxycycline, or azithromycin monotherapy)

If culture is not available, nucleic acid amplification tests (NAATs) are acceptable as a second choice test. If the NAAT is positive, a confirmatory culture is recommended. Antimicrobial susceptibility testing (AST) is recommended for all positive TOC cultures.

To reduce the risk of false positive test results when using NAATs, the TOC for gonorrhea should be delayed until at least seven days after treatment for anogenital infection, and 14 days after treatment for pharyngeal infection.  Clinicians using NAATs with combined results for chlamydia and gonorrhea should be aware that chlamydia results may remain positive for up to 3 weeks after successful treatment. Positive chlamydia test results before 3 weeks do not constitute treatment failure and do not require follow up TOC.

For assistance or clinical consultation regarding TOC, please call the STD Warm Line at (510) 620-3400, 8 am-5 pm, Monday-Friday and ask to speak with the clinician on call.

Suspected Gonorrhea Treatment Failure Management

Treatment failure should be suspected if (1) symptoms persist or recur following initial antibiotic therapy or (2) a TOC performed 7 days or more after treatment is positive for anogenital gonorrhea, and 14 days or more after treatment for pharyngeal gonorrhea. If symptoms are present, they may include:

• Persistent urethral discharge, dysuria, and/or pyuria (positive leukocyte esterase on urine dipstick)
• Persistent pharyngitis or odynophagia
• Persistent rectal discharge, pain, bleeding, pruritis, tenesmus, or painful defecation
• Persistent vaginal discharge, dysuria, or post-coital spotting

For patients with suspected treatment failure after dual antibiotic therapy, the following steps should be taken to ensure adequate testing, treatment, partner management, and follow up:

1. Obtain specimens for culture and NAAT at sites of sexual exposure (i.e., genital, rectal, pharyngeal). If gonorrhea culture is not available at your local laboratory, contact the California STD Control Branch clinician warm line for assistance at (510) 620-3400, M-F, 8am-5pm.
2. Treat the patient with ceftriaxone 500 mg IM plus azithromycin 2 g orally in a single dose.
3. Report the case to your local health department within 24 hours. Please also call the California STD Control Branch clinician warm line at (510) 620-3400 if consultation is desired.
4. Ensure that all of the patient’s partners in the last 60 days are notified and referred for testing and empiric treatment with ceftriaxone 500 mg IM plus azithromycin 2 g orally in a single dose. Your local health department may be able to provide assistance with partner notification.
5. Instruct the patient to abstain from oral, vaginal, or anal sex until one week after the patient and all of his/her partners are treated and all symptoms have resolved.
6. Ensure that the patient returns for a TOC one week after treatment with culture and NAAT.

The above recommendations are meant for patients with treatment failure after dual therapy with ceftriaxone or cefixime. Patients with persistent symptoms or a positive TOC after treatment with a non-recommended regimen (e.g. fluoroquinolones) should be treated with ceftriaxone 250 mg IM plus azithromycin 1g orally.  For patients with treatment failure after azithromycin monotherapy, call the STD Warm Line for consultation (see below). 

Patients with persistent or recurrent symptoms who report interim sexual exposure to untreated or new partners have likely been reinfected. Patients with reinfection should be retreated with the recommended regimen of ceftriaxone 250 mg IM plus azithromycin 1g orally.


For assistance or clinical consultation regarding patients with ongoing treatment failure, patients with severe allergies, or other challenging cases, please call the STD Warm Line at (510) 620-3400, 8 am-5 pm, Monday-Friday and ask to speak with the clinician on call. For more information about STDs, please visit the
STD Control Branch website.

Date Last Revised: 08/14/2014

 

 
 
Last modified on: 8/19/2014 12:43 PM