Gonorrhea

These materials are intended for general clinical education and guidance. They are not a substitute for a clinician’s knowledge, skill or judgment in treating patients.

Preferred treatments

• Ceftriaxone 500 mg IM/IV in a single dose (1 g if weight ≥ 150 kg)
  • May be given IV in patients with established IV access.
  • For IM injection only: dilute with 1.1 mL of 1 per cent lidocaine to reduce pain.
  • The proportion of Neisseria gonorrhoeae isolates with reduced ceftriaxone susceptibility in Ontario remains very low, but has increased in recent years; a higher ceftriaxone dose is therefore recommended.

Alternative treatments

• All alternatives are less effective than ceftriaxone; cefixime use has also been associated with accelerating population resistance to ceftriaxone
• Reduced susceptibility to azithromycin has been observed among Ontario Neisseria gonorrhoeae isolates (3.6–15 per cent from 2016 to 2020)
• If cephalosporin allergy: Gentamicin 240 mg IM/IV (if IM, give in two separate 3 mL injections of 40 mg/mL) PLUS azithromycin 2 g PO in a single dose
• If IM/IV administration is contraindicated (least preferred): Cefixime 800 mg PO in a single dose

Treatments in pregnancy

• Ceftriaxone 500 mg IM/IV in a single dose
• Consult a specialist if the preferred treatment cannot be used

Follow-up recommendations

• A test of cure is recommended if:
  • First-line therapy is not used
  • There is a known or suspected pharyngeal infection
  • Pregnancy
  • Suspected treatment failure
• Culture at least three days after treatment is recommended; NAAT at two weeks after treatment is an alternative
• Re-screen at three months after treatment

Testing and treatment of sexual contacts

• All partners with sexual contact with the index case within 60 days should be notified, tested and empirically treated; provide counselling and notify your local public health authority (Toronto Public Health STI Program: 416-338-2373); consider expedited partner therapy for contacts who are difficult to reach.
• Rectal and/or pharyngeal testing is recommended in MSM, people engaged in sex work, sexual contacts of a person with gonorrhea, or based on clinical assessment of risk and symptoms; NAAT is the preferred specimen type.