- Rates of the sexually transmitted infection gonorrhea have risen over the past two decades
- The preferred treatment for uncomplicated gonorrhea is the antibiotic ceftriaxone
- The recommended dose has increased to 500 mg given as a single intramuscular injection
Gonorrhea is a common sexually transmitted infection (STI). It can cause inflammation of affected tissue—usually in the anogenital tract and throat. Gonorrhea can contribute to pelvic inflammatory disease in women, can lead to infertility and can be transmitted to an infant during pregnancy, leading to blindness in the infant. The inflammation caused by gonorrhea can increase the risk for acquiring HIV infection. Since 1997, cases of gonorrhea have been increasing in Canada.
A scientific advisory panel to the Public Health Agency of Canada (PHAC) has released interim guidance for the treatment of gonorrhea.
In adults (and in young people 10 years of age and older), the advisory panel recommends the following treatment “for all uncomplicated infections (urethral, endocervical, vaginal, rectal and pharyngeal)”:
- the antibiotic ceftriaxone 500 mg given as an intramuscular injection in a single dose
Alternative antibiotics
The scientific advisory panel notes that “alternative treatment options, which are required if access to intramuscular injection is not available, if the individual refuses the injection, or if the individual is severely allergic to [cephalosporins – the class of antibiotic to which ceftriaxone belongs], are currently under review.” In the meantime, should ceftriaxone not be an option, PHAC recommends the following alternative antibiotics:
- cefixime 800 mg orally in a single dose + doxycycline 100 mg orally twice daily for seven consecutive days
- cefixime 800 mg orally in a single dose + azithromycin 1 g orally in a single dose
- azithromycin 2 g orally in a single dose + gentamycin 240 mg in a single intramuscular dose
- gentamicin 240 mg as a single intramuscular dose + doxycycline 100 mg orally twice daily for seven consecutive days
The panel states that doxycycline should not be used in pregnancy and in people who are lactating. They also state that gentamicin should not be used during pregnancy.
Other recommendations from the scientific advisory panel related to the management of gonorrhea can be found here. PHAC also has a Gonorrhea Guide.
No longer recommended
The panel notes that the following older regimens are no longer recommended by PHAC for the treatment of gonorrhea:
- ceftriaxone 250 mg as a single intramuscular injection + doxycycline 100 mg orally twice daily for seven consecutive days
- azithromycin 2 g in a single oral dose + ciprofloxacin 500 mg in a single oral dose
- azithromycin 2 g in a single oral dose + gemifloxacin 320 mg in a single oral dose
Note
Raising the dose of ceftriaxone to 500 mg is important, as worldwide there have been increasing reports of gonorrhea that is resistant to ceftriaxone. Such reports are rare in Canada, but if the lower dose of 250 mg was still in use, ceftriaxone-resistant gonorrhea would become more common. According to PHAC, “between 2017 and 2024, national surveillance has identified 13 cases of [gonorrhea] resistant to ceftriaxone.”
—Sean R. Hosein
Resources
Gonorrhea Guide: Treatment and follow-up – PHAC
Shrinking options for antibiotics in gonorrhea – TreatmentUpdate 245
Ertapenem seems similar in effectiveness to ceftriaxone for gonorrhea – TreatmentUpdate 245
Extremely high doses of ceftriaxone for gonorrhea in some parts of China – TreatmentUpdate 245
REFERENCES:
- National Advisory Committee on Sexually Transmitted and Blood-Borne Infections (NAC-STBBI). Interim guidance for the treatment of uncomplicated gonococcal infections. Advisory Committee Statement. 23 December 2024. Available at: https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/national-advisory-committee-stbbi/statements/interim-guidance-treatment-uncomplicated-gonococcal-infections.html
- Blouin K, Lefebvre B, Trudelle A, et al. Neisseria gonorrhoeae treatment failure to the recommended antibiotic regimen-Québec, Canada, 2015-19. Journal of Antimicrobial Chemotherapy. 2024 Nov 4;79(11):3029-3040.
- Blouin K, Lefebvre B, Trudelle A, et al. Correlates of Neisseria gonorrhoeae antimicrobial resistance: cross-sectional results from an open cohort sentinel surveillance network in Québec, Canada, 2016-2019. BMJ Open. 2023 Aug 4;13(8):e073849.
- Fifer H, Doumith M, Rubinstein L, et al. Ceftriaxone-resistant Neisseria gonorrhoeae detected in England, 2015-24: an observational analysis. Journal of Antimicrobial Chemotherapy. 2024 Dec 2;79(12):3332-3339.
- Unemo M, Golparian D, Oxelbark J, et al. Pharmacodynamic evaluation of ceftriaxone single-dose therapy (0.125-1 g) to eradicate ceftriaxone-susceptible and ceftriaxone-resistant Neisseria gonorrhoeae strains in a hollow fibre infection model for gonorrhea. Journal of Antimicrobial Chemotherapy. 2024 May 2;79(5):1006-1013.
- Xiu L, Wang L, Li Y, et al. Molecular screening to track ceftriaxone-resistant FC428-like Neisseria gonorrhoeae strains’ dissemination in four provinces of China, 2019 to 2021. Euro Surveillance. 2025 Feb;30(6).
- Laumen JGE, Hieu VN, Nhung PH, et al. High prevalence of ceftriaxone-resistant Neisseria gonorrhoeae in Hanoi, Vietnam, 2023-2024. Journal of Infectious Disease. 2025; in press.