A single dose of ceftriaxone is the drug of choice for uncomplicated urogenital, rectal, or pharyngeal gonorrhea. If ceftriaxone cannot be used because of cephalosporin allergy, a regimen such as gentamicin plus azithromycin or cefixime can be used. If chlamydial infection has not been excluded, anti-chlamydial therapy with doxycycline should be given.
Because reinfection rates are high, patients who have been treated for gonorrhea should be retested 3 months after treatment. A test-of-cure follow-up culture or NAAT is not necessary following treatment for genital or rectal gonorrhea but should be performed if the patient had pharyngeal gonorrhea.
Treatment of complicated gonococcal infections, such as PID, typically requires hospitalization. Treatment regimens are complex and beyond the scope of this book.
Prior to the mid-1950s, all gonococci were highly sensitive to penicillin. Subsequently, isolates emerged with low-level resistance to penicillin and to other antibiotics such as tetracycline and chloramphenicol. This type of resistance is encoded by the bacterial chromosome and is due to reduced uptake of the drug or to altered binding sites rather than to enzymatic degradation of the drug.
Then, in 1976, penicillinase-producing (PPNG) strains that exhibited high-level resistance were isolated from patients. Penicillinase is plasmid-encoded. PPNG strains are now common in many areas of the world, including several urban areas in the United States, where approximately 10% of isolates are resistant. Isolates resistant to fluoroquinolones, such as ciprofloxacin, have become a significant problem, and fluoroquinolones are not recommended as treatment. Isolates resistant to sulfonamides and tetracyclines have also been recovered. In 2017, the World Health Organization (WHO) reported that several strains of gonococci resistant to all known antibiotics have been isolated.
