Today’s pearl summarizes the recent updates from the CDC’s Treatment Guidelines for Gonococcal Infection.
Which antibiotics and what doses should be used? How do we reach effective concentrations in all patients?
The new CDC recommendation for treating uncomplicated gonorrhea of the cervix/urethra/rectum/pharynx is ceftriaxone 500 mg IM (MMWR Dec 18, 2020).
- Patients ≥ 150 kg should receive ceftriaxone 1 gm IM.
- If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 gm as a single dose is recommended to treat chlamydia.
- Azithromycin is no longer needed if only gonorrhea is being treated.
Back in the day, we used ceftriaxone 125 mg IM. In 2010, it changed to 250 mg based on resistance patterns. Now, a decade later, we’ve increased again.
For patient in whom ceftriaxone is NOT an option, we can still use gentamicin 240 mg IM plus azithromycin 2 gm orally as a single dose.
Now for something a little more outside the guidelines. In a different post, I discussed the potential to use IV ceftriaxone in place of IM ceftriaxone for patients who either already have a peripheral IV in place or who refuse an IM injection. Based on data from the package insert, I believe this still holds true despite the higher dose of IM ceftriaxone now being recommended. And, it’s backed up by data from Japan who has been using this approach since 2008 (Aoki 2021). Below you can see the measured ceftriaxone serum concentrations obtained following IM and IV administration.
|Average Plasma Concentrations (mcg/mL)|
|Ceftriaxone Dose/Route||0.5 hr||1 hr||2 hrs||4 hrs||8 hrs||12 hrs||16 hrs||24 hrs|
|0.5 gm IM||22||33||38||35||26||16||ND||5|
|1 gm IV||151||111||88||67||43||28||18||9|
|1 gm IM||40||68||76||68||44||29||ND||ND|
|2 gm IV||257||192||154||117||74||46||31||15|