Gonorrhea treatment: ceftriaxone and azithromycin

Gonorrhea is one of the most common sexually transmitted infections (STIs). It can affect the genitals, mouth, throat, eyes, and rectum and is caused by the bacteria, Neisseria gonorrhoeae.

According to the Centers for Disease Control and Prevention (CDC), approximately 820,000 new cases of gonorrhea occur in the United States each year (CDC, 2019-a). Over sixty percent of these are in young people aged 15-24 years old. A single interaction with an infected partner gives you a 30-70% chance of getting gonorrhea from them (Sherrard, 2014). Sexual contact of any type can lead to gonorrheal infection, including vaginal, anal, and oral sex.

Many men and most women never develop symptoms from gonorrhea. Sometimes the only way it is detected is through screening tests. The CDC has specific screening guidelines for people who should be tested for gonorrhea each year (CDC, 2015-a).

• All sexually active women younger than 25 years of age

• Older women at increased risk due to high-risk sexual behavior

• Sexually active men who have sex with men (MSM) at all exposure sites (urethra, rectum, pharynx)

• Sexually active HIV patients

Pregnant women also need to be tested and treated to prevent transmission to their newborns.

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Gonorrhea that remains untreated can have complications. These differ in men and women, but both can lead to long-term fertility issues. Therefore, both you and your partner must get treated.Untreated gonorrhea complications in men include the following (CDC, 2019-a): 

• Abscesses in the penis

• Epididymitis (infection and inflammation of the tube that stores and carries sperm)

• Scarring of the urethra (the tube that carries semen and urine in the penis)

• Infertility (rare)

Women have a higher risk of complications from untreated gonorrheal infections than men (Sherrard, 2014). Pelvic inflammatory disease (PID) is one of the most common of these complications. This condition occurs when the untreated infection travels up into the uterus, fallopian tubes, and ovaries.Symptoms of PID include:

• Lower abdominal or pelvic pain

• Vaginal discharge or bleeding

• Pain or bleeding with sexual intercourse

• Pain with urination

• Fevers and/or chills

• Nausea and/or vomiting

If PID is found early, it can be treated. However, any damage that has been done by the infection and inflammation cannot be reversed. Approximately 1 in 8 women who have had PID at some point in their past will have difficulties getting pregnant. PID that is left untreated can have complications including (CDC, 2015-b):

• Endometritis (inflammation of the wall of the uterus)

• Abscesses in the ovaries or fallopian tube (tubo-ovarian abscess)

• Scar tissue both outside and inside the fallopian tubes (tubes that carry eggs from the ovary to the uterus); this scarring can lead to permanent blockage.

• Ectopic pregnancy (fertilized egg implanting outside of the uterus).

• Inability to get pregnant (infertility)

• Long-term pelvic/abdominal pain

In both men and women, there is a risk of the infection spreading throughout the body- disseminated gonococcal infection (DGI). Fortunately, this occurs in only 0.4-3% of patients with gonorrhea, often 2-3 weeks after infection (Morgan, 2016). Common symptoms of DGI include tenosynovitis (inflammation around tendons), arthralgia/arthritis (joint pain/inflammation), fever, and rash. DGI can occur without symptoms of genital, rectal, or oral gonorrhea infection (Lohani, 2016). This condition can be life-threatening if left untreated.

Once diagnosed with gonorrhea, both you and your partner(s) must receive prompt treatment. In most cases, gonorrhea can be treated with a single dose of antibiotics. However, as with many other bacteria, we are starting to see the emergence of antibiotic-resistant gonorrhea (ARG).  This means that the bacteria are coming up with ways to resist being killed by our currently available drugs. Based on data collected over the years, ARG emerges every 10-20 years (Morgan, 2016).  According to the CDC, gonorrhea has become resistant to nearly all of the antibiotics that have been used to treat it (CDC, 2019-b). There is currently one class of antibiotics, cephalosporins, that is still effective. The FDA is conducting clinical trials on new antibiotics that may be useful in treating ARG (NIH, 2018)

The CDC treatment guidelines recommend dual therapy with two different antibiotics: ceftriaxone (a cephalosporin) and azithromycin (CDC, 2015-c). Each of these antibiotics has a different mechanism of action against N. gonorrhea (the bacteria that causes gonorrhea). This two-pronged approach increases the chances that the treatment will be effective. We know that cephalosporins work against gonorrhea and the addition of the azithromycin will hopefully slow down the emergence of antibiotic resistance to the cephalosporins (CDC, 2019-a). There is another reason for using azithromycin in combination with ceftriaxone. Many people who are infected with gonorrhea are also infected with chlamydia, another STI; azithromycin is effective in treating chlamydia. These two antibiotics are typically each given as a single dose at the same time; for most people, this will cure the infection. In the case of DGI, treatment needs to be continued for at least seven days.After treatment, you should abstain from sexual activity for at least seven days to prevent transmission. People who have recurrent symptoms have been found to have a repeat infection and not incomplete treatment (Morgan, 2016). If you are treated for gonorrhea, you should be retested three months later (CDC, 2015-c). You should also be tested for other STIs, such as chlamydia, syphilis, and HIV.Because of the risk of complications from untreated gonorrhea and the risk of spread, any of your recent sexual partners must also be treated. Your sexual partner(s) needs to be made aware of their potential risk for infection so that they get tested and treated if necessary.

After gonorrhea treatment, it takes a few days for the symptoms to resolve completely. The antibiotics are very effective at treating gonorrhea. Unfortunately, they cannot reverse any damage, such as scarring, that the infection may have caused. Early treatment is vital to prevent future problems. If the symptoms have not resolved after a few days, you should follow up with your healthcare provider for possible re-evaluation.

Unfortunately, there are no drugs or vaccines that prevent gonorrhea. The best way to avoid gonorrhea is by employing safe sex practices, including the use of condoms. Getting a gonorrhea Infection does not protect you against future infections.

Gonorrhea is a common STI that is treatable. However, if you wait too long to get treatment, you run the risk of having serious complications, like scarring, PID, and possible future fertility issues. Know your STI status and encourage your sexual partner to do the same. Practicing safe sexual practices is the only way to prevent the transmission of gonorrhea.

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Current version

August 22, 2019

Written by

Chimene Richa, MD

Fact checked by

Tzvi Doron, DO

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About the medical reviewer

Tzvi Doron, DO

Dr. Tzvi Doron is Board Certified in Family Medicine by the American Board of Family Medicine.