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Table 3 Recommended and alternative treatments for uncomplicated Neisseria gonorrhoeae infections of the urethra, cervix, rectum and pharynx in adults and youth in Europe, United Kingdom, Germany, Australia, USA, and Canada

From: Current and future antimicrobial treatment of gonorrhoea – the rapidly evolving Neisseria gonorrhoeae continues to challenge

  Europe [61] United Kingdom [62] Germany [63] Australia [64] USA [65] Canada [66]
Recommended (first-line) regimens for anogenital infections a Ceftriaxone 500 mg × 1 IM Ceftriaxone 500 mg × 1 IM Ceftriaxone 1 g × 1 IM/IV Ceftriaxone 500 mg × 1 IM Ceftriaxone 250 mg × 1 IM Ceftriaxone 250 mg × 1 IM
PLUS PLUS PLUS PLUS PLUS PLUS
Azithromycin 2 g × 1 orallyb Azithromycin 1 g × 1 orally Azithromycin 1.5 g × 1 orally Azithromycin 1 g × 1 orally Azithromycin 1 g × 1 orally Azithromycin 1 g × 1 orally
OR
Cefixime 800 mg × 1 orally
PLUS
Azithromycin 1 g × 1 orally
Alternative regimens for anogenital infections a 1. Cefixime 400 mg × 1 orally All the options below should be taken with Azithromycin 1 g × 1 orally.c If IM/IV injection is not possible: Alternative treatments are not recommended because of high levels of resistance, except for some remote Australian locations and severe allergic reactions. If ceftriaxone is not available: Spectinomycin 2 g × 1 IM
PLUS → Cefixime 400 mg × 1 orally. Only if an injection contra-indicated or refused. Cefixime 800 mg × 1 orally   Cefixime 400 mg × 1 orally PLUS
Azithromycin 2 g × 1 orally. → Spectinomycin 2 g × 1 IM. PLUS   PLUS Azithromycin 1 g × 1 orally
Only if ceftriaxone not available or administration of injectable antimicrobials not possible or refused. → Cefotaxime 500 mg × 1 IM or Cefoxitin 2 g × 1 IM PLUS probenecid 1 g × 1 orally. Azithromycin 1.5 g × 1 orally   Azithromycin 1 g × 1 orally OR
2. Ceftriaxone 500 mg × 1 IM. Other cephalosporins offer no advantage in terms of efficacy and pharmacokinetics over ceftriaxone or cefixime. or if N. gonorrhoeae known to be susceptible:    Azithromycin 2 g × 1 orally
Only if azithromycin not available or patient unable to take oral medication.c → Cefpodoxime with caution at a dose of 400 mg × 1 orally. → Cefixime 400 mg × 1 orally    
3. Spectinomycin 2 g × 1 IM → When an infection is known before treatment to be quinolone susceptible, ciprofloxacin 500 mg × 1 orally or ofloxacin 400 mg × 1 orally. → Ciprofloxacin 500 mg × 1 orally or Ofloxacin 400 mg × 1 orally.    
PLUS   → Azithromycin 1.5 g × 1 orally    
Azithromycin 2 g × 1 orally.      
E.g., if resistance to extended-spectrum cephalosporins is identified or suspected, or patient has history of penicillin anaphylaxis or cephalosporin allergy.      
Recommended treatment for pharyngeal infections Identical regimen as recommended for anogenital infections. Identical regimen as recommended for anogenital infections. Identical regimen as recommended for anogenital infections. Identical regimen as recommended for anogenital infections. Identical regimen as recommended for anogenital infections. Ceftriaxone 250 mg × 1 IM
   OR if N. gonorrhoeae known to be quinolone susceptible: OR if N. gonorrhoeae known to be susceptible:    PLUS
   → Ciprofloxacin 500 mg × 1 orally or Ofloxacin 400 mg × 1 orally. → Ciprofloxacin 500 mg × 1 orally or Ofloxacin 400 mg × 1 orally.    Azithromycin 1 g × 1 orally
    → Azithromycin 1.5 g × 1 orally    Alternatives:
       Cefixime 800 mg × 1 orally
       PLUS
       Azithromycin 1 g × 1 orally
       OR
       Azithromycin 2 g × 1 orally.
Recommended regimen when extended-spectrum cephalosporin resistance identified or failure with recommended dual regimen → Ceftriaxone 1 g × 1 IM No recommendation. No recommendation. No recommendation. → Retreatment with recommended dual regimen. It is strongly recommended that treatment be guided by antimicrobial susceptibility test results to determine the appropriate antimicrobial agent in consultation with an expert in infectious diseases and local public health authorities.
PLUS     → Gemifloxacin 320 mg × 1 orally  
     PLUS  
     Azithromycin 2 g × 1  
Azithromycin 2 g × 1 orally.     OR  
→ Gentamicin 240 mg × 1 IM     Gentamicin 240 mg × 1 IM  
PLUS     PLUS  
Azithromycin 2 g × 1 orally.b     Azithromycin 2 g × 1 can be considered.  
  1. IM intramuscularly, IV intravenously
  2. aUncomplicated gonococcal infections of the cervix, urethra and rectum
  3. bAzithromycin tablets may be taken with or without food but gastrointestinal side effects can be less if taken after food
  4. cCo-infection with Chlamydia trachomatis is common in young (<30 years) heterosexual individuals and men who have sex with men (MSM) with gonorrhoea. If treatment for gonorrhoea does not include azithromycin, treatment with azithromycin 1 g × 1 orally or doxycycline 100 mg orally twice daily for 7 days should be given for possible chlamydial co-infection unless co-infection has been excluded with nucleic acid amplification test (NAAT)