The revised CDC guidelines now recommend a single 500 IM dose of ceftriaxone for urogenital, rectal, and pharyngeal gonorrhea. A single 1 g IM dose of ceftriaxone should be given to patients weighing more than 150 kg, although such dosing demands consideration of using the intravenous route, which is just as effective as IM administration. Adding doxycycline 100 mg orally two times a day for seven days should be the norm in the ED where chlamydial co-infection is rarely excluded.
Updated treatment recommendations regarding the most common pathogens with increasing resistance rates of antibiotic resistance...
In 07/2021, the CDC released the first updates to their guidelines in 5 years on the treatment of sexually transmitted infections (STIs). These are consensus guidelines meant to provide an approach for those providers treating suspected and documented sexually transmitted infections, especially in the setting of increasing antibiotic resistance and globalization resulting in increasing prevalence of STIs previously seen mostly abroad. Although some of these guidelines have been previously stated by the CDC, this is the first comprehensive set of guidelines in the last 5 years.
Resistance of these STIs to the effect of antibiotics has increased rapidly in recent years and has reduced treatment options. Of the 3 STIs, gonorrhoea has developed the strongest resistance to antibiotics. Strains of multidrug-resistant gonorrhoea that do not respond to any available antibiotics have already been detected. Antibiotic resistance in chlamydia and syphilis, though less common, also exists, making prevention and prompt treatment critical.
World Health Organization unveils new treatment guidelines to cope with antibiotic resistance.
When the new Centers for Disease Control and Prevention (CDC) recommendations regarding the treatment of uncomplicated gonorrhea (and indirectly chlamydia) debuted like a slice of antibiotic resistance doom, it felt like another “gift” had arrived from 2020. Intramuscular (IM) ceftriaxone dosing has increased from 250 mg to 500 mg (or 1 g for weight ≥150 kg). Empiric chlamydia coverage switched from a single dose of 1 g of azithromycin to doxycycline 100 mg PO BID for 7 days. Being deferential to CDC expertise, many providers accepted them uncritically. Compliance rates with a switch from a 1-time to a 7-day regimen are not addressed, especially worrisome for a condition that can be minimally or asymptomatic.
In cases where gonorrhea expedited partner therapy (provision of prescriptions or medications for the patient to take to his or her sex partner without the health care provider first examining the partner) is permissible by state law and the partner is unable or unlikely to seek timely treatment, the partner may be treated with a single 800 mg dose of cefixime, if a chlamydia infection in the patient has been excluded. If a chlamydia test result has not been documented, the partner may be treated with a single dose of oral cefixime 800 mg plus oral doxycycline 100 mg 2 times/day for 7 days. If adherence with multiday dosing is a considerable concern, azithromycin 1 g can be considered but has lower treatment efficacy among persons with rectal chlamydia.
New empiric treatment regimen: Ceftriaxone 500mg IM x1 + Doxycycline 100mg PO BID x7d (Remember that pregnancy and obesity (>150kg) have different recommendations).
a single 500 mg IM dose of ceftriaxone is the new recommended regimen. For patients weighing ≥150 kg (300 lbs.), a higher dose is needed, and a single 1 gram IM dose of ceftriaxone should be administered. If ceftriaxone is not available, the alternative regimen is a single 240 mg IM dose of gentamicin plus a single 2 g oral dose of azithromycin or monotherapy of cefixime 800 mg orally in a single dose. If there is a coinfection with Chlamydia trachomatis, the recommended regimen of doxycycline 100 mg twice daily orally for 7 days should be added to the treatment plan. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.
For cephalosporin allergic, 2 options: – Gentamicin 240 mg IM (or 5mg/kg IM) with azithromycin 2g orally OR – Gemifloxacin 320 mg orally with azithromycin 2g orally.
“Our ultimate goal is to have clinicians utilize a test-and-treat algorithm so that you don’t have to use these empiric therapies,” Denver said.
Gonorrhea may not seem like a big deal. Aside from HIV, sexually transmitted diseases seem like solved problems, relics of some long-ago time when sex wasn’t discussed and sexual health care was difficult to access.
In fact, gonorrhea is surging back, along with its equally forgotten partner, syphilis.
Perhaps the most significant change in the new recommendations is for a single 500 mg IM dose of ceftriaxone for uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, doubling the dose from 250 mg. Where there is concern for coinfection with Chlamydia trachomatis (often the case when urogenital infections are treated empirically in the ED), the CDC recommended adding oral doxycycline 100 mg twice a day for seven days, not the dose or two of azithromycin that much of ED practice has shifted to over the years.
These guidelines reflect the 2021 CDC STI Treatment Guidelines for adults and adolescents who are HIV negative as well as those with HIV.
CDC’s Sexually Transmitted Infections (STI) Treatment Guidelines, 2021 provides current evidence-based prevention, diagnostic and treatment recommendations that replace the 2015 guidance.