Use ceftriaxone or azithromycin for gonorrhea, now that cefixime and spectinomycin are unavailable
- Cefixime and spectinomycin, antibiotics with unique application for treatment of uncomplicated gonorrhea in pregnant women, were recently withdrawn from the market. In their absence, use ceftriaxone,125 mg intramuscularly in a single dose. Pregnant women who are allergic to beta-lactam antibiotics should be treated with a single 2-g oral dose of azithromycin.
Two antibiotics with unique application in treatment of uncomplicated gonococcal infections were recently withdrawn from the market. These drugs were not withdrawn because there were questions about their effectiveness or safety. Rather, the decisions to discontinue production appear to have been based on marketing and economic considerations.
- Cefixime, an oral cephalosporin that was highly effective in a single 400-mg dose against almost all strains of N gonorrhoeae.
- Spectinomycin, a parenteral agent (2 g, intramuscularly) that was the treatment of choice for uncomplicated gonorrhoeae in pregnant women allergic to beta-lactam antibiotics.
Recommendations
Nonpregnant women can be treated with either ceftriaxone, 125 mg IM in a single dose, or with a single oral dose of a quinolone antibiotic; for example, 500 mg ciprofloxacin, 400 mg ofloxacin, or 250 mg levofloxacin.
Pregnant women who are not allergic to beta-lactam antibiotics should be treated with ceftriaxone, 125 mg IM in a single dose.
Dilemma: Beta-lactam allergy in pregnant women
The dilemma is how best to treat pregnant patients who are allergic to beta-lactam antibiotics, now that spectinomycin is unavailable. Doxycycline and tetracycline provide reasonable coverage against N gonorrhoeae, but both are considered FDA pregnancy category D. Quinolone antibiotics have excellent activity against this organism, but they are considered FDA pregnancy category C because of concern about their effect on fetal cartilage.
Azithromycin is an acceptable alternative. For the pregnant patient who has a true life-threatening allergy to beta-lactams, I believe the most reasonable alternative is azithromycin. This drug is usually used in a single oral dose of 1 g to treat uncomplicated chlamydial infections. However, in a dose of 2 g, azithromycin does have acceptable activity against N gonorrhoeae. At this dosage, gastrointestinal effects are more likely, and cost may exceed $80.