Gonorrhea

Clinical Snapshot

Guidance changed in January 2025: the preferred treatment for gonorrhea is now ceftriaxone 500 mg IM as a single dose, given alone — azithromycin is no longer part of the preferred regimen. This is a higher ceftriaxone dose than older references still show, and it replaces the previous standard of ceftriaxone 250 mg plus azithromycin 1 g. If you have seen "ceftriaxone plus azithromycin" described as standard therapy, that reflects guidance PHAC has since revised.^[1]

Gonorrhea, caused by Neisseria gonorrhoeae, is — together with chlamydia — one of the 2 major causes of urethritis and cervicitis. Chlamydia co-infection is common, which is why current guidance still recommends chlamydia co-treatment whenever chlamydia has not been ruled out by a negative test, even though azithromycin (which used to serve double duty against both organisms) is no longer routinely given for gonorrhea itself.^[2]

Recognize the Condition

Typical Presentation

Can affect the urethra, cervix, pharynx, rectum, or (rarely) disseminate.

In people with a penis: purulent urethral discharge and often severe dysuria.
In people with a vagina: increased vaginal discharge, dysuria, intermenstrual bleeding — but infection can also be entirely asymptomatic.
Pharyngeal and rectal infection are frequently asymptomatic and are easy to miss without site-specific testing based on exposure history.
Untreated infection can ascend to cause pelvic inflammatory disease, which can lead to infertility.
Rarely, infection disseminates: fever, skin lesions, and joint involvement (disseminated gonococcal infection) — this needs urgent specialist involvement, not outpatient management.

Risk Factors

Sexual exposure to a partner with confirmed or suspected gonorrhea.
New or multiple sexual partners, particularly under 30 years of age.
Concurrent chlamydia infection or other STI.
Sex without barrier protection.
Pregnancy — universal screening is recommended regardless of other risk factors.

Red Flags & Refer

Escalate urgently or refer for any of the following:

Fever with skin lesions or joint pain — possible disseminated gonococcal infection.
Signs of pelvic inflammatory disease.
Testicular pain — rule out testicular torsion urgently, a separate surgical emergency.
Suspected treatment failure after the current preferred regimen — this raises concern for ceftriaxone resistance and needs culture-based susceptibility testing, not simply a repeat of the same treatment.

Assessment & Diagnosis

Testing

NAAT is the most sensitive test and the default choice.
Also send a culture whenever feasible — this is more important for gonorrhea than for most other STIs, because culture is what allows antimicrobial susceptibility testing. Prioritize culture collection for: suspected treatment failure, infection acquired in an area with known high resistance rates, symptomatic patients, pelvic inflammatory disease, pregnancy, sexual assault, or an asymptomatic patient identified as a contact of a known case.^[3]
Test extragenital sites (pharynx, rectum) based on exposure history.
Because co-infection is common, test for chlamydia whenever gonorrhea is suspected, and screen for syphilis and HIV at the same visit.

Treatment Targets

Eradicate N. gonorrhoeae at every infected site.
Eradicate infection in all recent (under 60 days) sexual partners.
Prevent ascending and disseminated complications.
Prevent vertical transmission (ophthalmia neonatorum, neonatal systemic infection) when the patient is pregnant.

Choose Initial Treatment

Current preferred regimen (all uncomplicated sites, all ages 10+, including pregnancy)

Ceftriaxone 500 mg IM as a single dose, given alone.

This single regimen now applies uniformly to urethral, endocervical, vaginal, rectal, and pharyngeal infection — pharyngeal infection previously needed a different combination approach, but no longer does under current guidance.^[1]

Chlamydia co-treatment rule

If chlamydia has not been excluded by a negative test, add chlamydia treatment (see the Chlamydia chapter) — this is a separate decision from the gonorrhea regimen itself, not a routine addition to it.

Do not use as the preferred regimen

Do not use ceftriaxone 250 mg plus azithromycin — this was the previous standard and is now superseded.

Do not use azithromycin as gonorrhea monotherapy under any circumstances; sporadic resistance has emerged in Canada.^[2]

Non-Pharmacologic Treatment

Abstain from sexual intercourse for 7 days after starting adequate treatment, and until all sexual partners have also been treated.
Refer all recent (under 60 days) sexual partners for testing and empiric treatment.
Reinforce barrier protection for ongoing risk reduction, given how common reinfection is.

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Ceftriaxone Preferred	Monotherapy for all uncomplicated sites, ages 10+, including pregnancy	500 mg IM as a single dose	GI upset, hypersensitivity reactions	January 2025 interim guidance. Given alone, without azithromycin, unless chlamydia has not been excluded — see Choose Initial Treatment.
Cefixime + doxycycline Alternative	Cephalosporin allergy interim option	Combo: cefixime 800 mg PO single dose + doxycycline 100 mg PO BID for 7 days	Cefixime: GI upset, hypersensitivity. Doxycycline: GI upset, rash	Not preferred first-line.
Azithromycin + gentamicin Alternative	Cannot receive any cephalosporin	Combo: azithromycin 2 g PO single dose + gentamicin 240 mg IM single dose	Azithromycin: GI upset, rare QT prolongation. Gentamicin: ototoxicity, nephrotoxicity	Prophylactic antiemetics may be needed for the 2 g azithromycin dose.
Gentamicin + doxycycline Alternative	Cannot receive a cephalosporin, macrolide-resistant infection	Combo: gentamicin 240 mg IM single dose + doxycycline 100 mg PO BID for 7 days	Gentamicin: ototoxicity, nephrotoxicity. Doxycycline: GI upset, rash	Monitor renal function and gentamicin levels.

Scope: this interim guidance covers uncomplicated infection only — pelvic inflammatory disease and other complicated gonococcal infections are managed differently (see the Pelvic Inflammatory Disease chapter).^[1]

Special Populations

Pregnancy: screen every pregnant patient at the first prenatal visit. Untreated gonococcal infection can cause endometritis and pelvic sepsis in the patient, and ophthalmia neonatorum and systemic infection in the newborn. Ceftriaxone 500 mg IM single dose is the preferred treatment and is included in the current guidance for pregnant patients specifically — this is unchanged by the interim update. Always treat for chlamydia at the same time in a confirmed gonococcal infection. Abstain from intercourse for 7 days after treatment and until partners are treated; arrange test-of-cure 3-4 weeks after completing therapy.^[2]

Cephalosporin allergy

Use one of the alternative regimens in Drug Tables. A documented history of anaphylaxis to penicillin also changes which alternative is appropriate — review the specific allergy history rather than treating all "penicillin allergy" labels the same way.

Monitoring & Follow-Up

Test of cure is now recommended for every positive site, not only in selected situations — this is a change from prior practice. If test of cure is done 3-21 days after completing treatment, use culture regardless of symptom status. If done more than 21 days after treatment, use NAAT if the patient is asymptomatic, or both culture and NAAT if symptomatic.^[1]
Repeat screening is recommended 6 months after treatment for all treated patients.
A patient previously treated with the older ceftriaxone-250-mg-plus-azithromycin regimen does not need retreatment on that basis alone, but test of cure is particularly important for anyone who received a regimen other than ceftriaxone 500 mg.

Treatment Failure / Next Step

Confirm the correct regimen and dose were actually given.
Confirm partners were tested and treated, and ask about re-exposure.
Send both culture and NAAT for test of cure — culture is essential here to allow susceptibility testing if resistance is a concern.
If treatment failure is confirmed with adherence and re-exposure excluded, obtain expert guidance before retreating — this pattern should prompt evaluation for resistant infection, not simply repeating ceftriaxone.
Reassess for pelvic inflammatory disease, epididymitis, or disseminated infection if new systemic or localizing symptoms have developed.

Common Errors to Avoid

Prescribing the outdated ceftriaxone 250 mg plus azithromycin combination as though it were still preferred.
Using azithromycin alone to treat gonorrhea.
Skipping culture collection when it is feasible and indicated — NAAT alone cannot tell you about resistance.
Assuming pharyngeal infection still needs a different regimen than genital/rectal infection — under current guidance it does not.
Withholding chlamydia co-treatment reflexively, or conversely, adding it automatically without checking whether chlamydia has actually been excluded.

Clinical Decision Algorithm

Gonorrhea treatment selection (January 2025 interim guidance)

Confirmed or strongly suspected uncomplicated gonorrhea (urethral, endocervical, vaginal, rectal, or pharyngeal)

Signs of PID, disseminated infection, or epididymo-orchitis

This is a complicated infection — manage per the Pelvic Inflammatory Disease chapter or refer; this algorithm does not apply

Uncomplicated infection, no cephalosporin allergy

Ceftriaxone 500 mg IM single dose (monotherapy)

Chlamydia not excluded by negative test

Add chlamydia treatment (doxycycline 100 mg PO BID x 7 days, or azithromycin 1 g PO single dose if pregnant) — see Chlamydia chapter

Chlamydia excluded

Ceftriaxone alone is complete treatment

Cephalosporin-resistant infection, or history of anaphylaxis to penicillin/cephalosporin allergy: select an interim alternative regimen based on the specific pattern

No true cephalosporin allergy

Cefixime 800 mg PO single dose + doxycycline 100 mg PO BID x 7 days

or: cefixime 800 mg PO single dose + azithromycin 1 g PO single dose

Cannot receive any cephalosporin

Azithromycin 2 g PO single dose + gentamicin 240 mg IM single dose

No cephalosporin, macrolide-resistant

Gentamicin 240 mg IM single dose + doxycycline 100 mg PO BID x 7 days

Refer all recent (under 60 days) sexual partners for testing and empiric treatment

Test of cure for every positive site (culture if within 21 days; NAAT ± culture after 21 days), then repeat screening at 6 months

Drug Tables

How to use this table: This table reflects PHAC's January 2025 interim guidance, which supersedes older ceftriaxone-plus-azithromycin recommendations still found in some secondary sources. Doses are adult doses and require patient-specific confirmation. Treat sexual partners. Select any drug name to open its complete Pharmasist Drug Database page.

Cephalosporins, Third-Generation — Preferred

Preferred monotherapy for all uncomplicated anogenital and pharyngeal infection, ages 10 years and older, including pregnancy.

Drug	Dosage	Adverse effects	Comments
Ceftriaxone generics	500 mg IM as a single dose (all ages 10+ and all uncomplicated sites, including pharyngeal, including pregnancy).	GI upset, hypersensitivity reactions.	Preferred regimen as of the January 2025 interim update — given alone, without azithromycin, unless chlamydia has not been excluded. May be mixed with 1-2 mL of 1% lidocaine to reduce injection pain. Do not reconstitute or co-administer with calcium-containing IV solutions.

Interim Alternative Regimens — Cephalosporin Allergy or Suspected Resistance

Reserve for a documented cephalosporin allergy, history of anaphylaxis to penicillin, or confirmed/suspected cephalosporin-resistant infection. Use culture-based susceptibility data to guide selection whenever available.

Drug	Dosage	Adverse effects	Comments
Cefixime + doxycycline Suprax, generics	Combo: cefixime 800 mg PO single dose + doxycycline 100 mg PO BID x 7 days	Cefixime: GI upset, hypersensitivity. Doxycycline: GI upset, rash, photosensitivity.	An interim alternative option — not preferred first-line.
Cefixime + azithromycin Suprax, generics	Combo: cefixime 800 mg PO single dose + azithromycin 1 g PO single dose	Cefixime: GI upset, hypersensitivity. Azithromycin: GI upset, rare QT prolongation.	An interim alternative option, still using a cephalosporin — not appropriate for true cephalosporin allergy.
Azithromycin + gentamicin Zithromax, generics	Combo: azithromycin 2 g PO single dose + gentamicin 240 mg IM single dose	Azithromycin: GI upset, rare QT prolongation. Gentamicin: ototoxicity, nephrotoxicity — monitor renal function and levels.	For patients who cannot receive any cephalosporin. Prophylactic antiemetics may be needed for the 2 g azithromycin dose.
Gentamicin + doxycycline generics	Combo: gentamicin 240 mg IM single dose + doxycycline 100 mg PO BID x 7 days	Gentamicin: ototoxicity, nephrotoxicity. Doxycycline: GI upset, rash, photosensitivity.	For patients who cannot receive a cephalosporin and have macrolide-resistant infection or macrolide allergy.

Not recommended: fluoroquinolones are not recommended for empiric gonorrhea treatment in Canada given resistance patterns, and should only be used when susceptibility has been demonstrated by culture or local resistance is confirmed to be very low with a planned test of cure.

Evidence note: Reflects PHAC's January 2025 interim guidance on gonorrhea treatment.^[1]

References

Interim guidance on the treatment of Neisseria gonorrhoeae infections — Public Health Agency of Canada. Interim update, January 2025
Sexually transmitted and blood-borne infections: Guides for health professionals — Public Health Agency of Canada. Canadian Guidelines on Sexually Transmitted Infections
Gonococcal Antimicrobial Surveillance Program — Canada (GASP-Canada): ceftriaxone — Public Health Agency of Canada. Health Infobase Canada

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.