In 2019, during an in-person meeting of governmental and nongovernmental participants, CDC staff members and subject matter experts reviewed data and presented their individual expert opinions. ... Cefixime+Azithromycin is a fixed-dose combination of two antibiotics and is used to treat patients with bacterial infections. Appropriate chlamydial testing should be done simultaneously in neonates with gonococcal infection. For a standard gonorrhea infection, a single 400-mg dose can be used. For persons with suspected cephalosporin treatment failure, the treating clinician should consult an infectious-disease specialist, an STD/HIV Prevention Training Center clinical expert (http://www.nnptc.orgexternal icon), the local or state health department STD program, or CDC (telephone: 404-718-5447) for advice on obtaining cultures, antimicrobial susceptibility testing, and treatment. For more information, see Chlamydia Infection in Neonates. Sexually transmitted diseases treatment guidelines, 2015. Treatment for DGI should be guided by the results of antimicrobial susceptibility testing. In addition, evidence supports increasing concern for the efficacy of azithromycin to treat chlamydial infections, especially rectal infections (15,16). 30th ed. If chlamydia coinfection is identified when pharyngeal gonorrhea testing is performed, providers should treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. Antimicrobial stewardship. In the United States, an estimated 820,000 new N. gonorrhoeae infections occur each year (533). Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. If azithromycin allergic, doxycycline (100 mg PO BID for 7 days) can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime. Gratrix J, Bergman J, Egan C, Drews SJ, Read R, Singh AE. Chisholm SA, Mouton JW, Lewis DA, Nichols T, Ison CA, Livermore DM. For more information, see Gonococcal Infections in Adolescents and Adults. Antimicrobial resistance in. Providers treating persons with cephalosporin or IgE-mediated penicillin allergy should consult an infectious-disease specialist. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. The total recruitment will be 1500 patients across sites in Bangladesh, India, Nepal and Pakistan. Clin Infect Dis 1995;20(Suppl 1):S47–65. It is usually an acute illness that manifests 2–5 days after birth. A test-of-cure is unnecessary for persons with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens; however, for persons with pharyngeal gonorrhea, a test-of-cure is recommended, using culture or nucleic acid amplification tests 7–14 days after initial treatment, regardless of the treatment regimen. Infants who have DGI should be managed in consultation with an infectious-disease specialist. Blumer JL, Reed MD, Kaplan EL, Drusano GL. Neither hemodialysis nor peritoneal di… Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. You can get gonorrhea and chlamydia from having any kind of sexual contact (oral, vaginal, or anal) with a person who already has them. CDC twenty four seven. GISP data show that the ceftriaxone MIC50 and MIC90 (MIC required to inhibit growth of 50% and 90% of organisms, respectively) were only one doubling dilution higher during 2014–2018, compared with the respective ceftriaxone MIC50 and MIC90 during 1992–1995 (1). A 250 mg ceftriaxone dose does not reliably achieve levels higher than an MIC ≥0.125 μg/mL for an extended duration (18). Culture and NAAT are available for the detection of genitourinary infection with N. gonorrhoeae (394); culture requires endocervical (women) or urethral (men) swab specimens. Regimen for uncomplicated gonococcal infections of the cervix, urethra, or rectum: Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, or rectum if ceftriaxone is not available: Regimen for uncomplicated gonococcal infections of the pharynx: Centers for Disease Control and Prevention. Updates for the remaining gonorrhea recommendations are forthcoming. No data exist on the use of dual therapy for the treatment of DGI or gonococcal scalp abscesses. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. Disseminated gonococcal infection (DGI) frequently results in petechial or pustular acral skin lesions, asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis (581). Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature. Consider one-time lavage of the infected eye with saline solution. Second-Line Therapy Source: CDC. Symptoms that persist after treatment should be evaluated by culture for N. gonorrhoeae (with or without simultaneous NAAT), and any gonococci isolated should be tested for antimicrobial susceptibility. so should i take all 8 pills together? For most infections, azithromycin is taken once daily for a relatively short course of treatment (usually five days). Since publication of the 2015 Sexually Transmitted Diseases (STD) Treatment Guidelines, concerns regarding antimicrobial stewardship have increased, especially the impact of antimicrobial use on the microbiome and data indicating azithromycin resistance (elevated MICs) for gonorrhea and other organisms (1,3). Azithromycin has unique pharmacokinetics that may make single dose regimens feasible. Macrolide and nonmacrolide resistance with mass azithromycin distribution. Genomic epidemiology data confirm that azithromycin resistance can result from multiple mechanisms (23). Cephalosporin treatment failure is the persistence of N. gonorrhoeae infection despite appropriate cephalosporin treatment and is indicative of infection with cephalosporin-resistant gonorrhea in persons whose partners were adequately treated and whose risk for reinfection is low. Appropriate chlamydial testing should be done simultaneously from the inverted eyelid specimen (see Ophthalmia Neonatorum Caused by C. trachomatis). All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing. 6 months to 12 years: This update provides the rationale for the change in gonorrhea treatment recommendations to a higher dose (500 mg) of ceftriaxone and removal of azithromycin from the recommended regimen. If prophylaxis is delayed (i.e., not administered in the delivery room), a monitoring system should be established to ensure that all infants receive prophylaxis. J Antimicrob Chemother 2010;65:2141–8. Neonates should be tested for gonorrhea at exposed sites and treated presumptively for gonorrhea as recommended in these guidelines. In 2007, based on data from CDC’s Gonococcal Isolate Surveillance Project* (GISP) indicating widely disseminated quinolone-resistant gonococcal strains in the United States, CDC no longer recommended fluoroquinolones for treatment, leaving cephalosporins as the only remaining recommended antimicrobial class (6). N Engl J Med 2019;380:2271–3. If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. Prenatal screening and treatment of pregnant women is the best method for preventing GC infection among neonates. Pending antimicrobial susceptibility results, treatment decisions should be made on the basis of clinical presentation. Dual treatment with single doses of intramuscular gentamicin 240 mg plus oral azithromycin 2 g can be considered, particularly when isolates are found to have elevated cephalosporin MICs (569). The high frequency of pharyngeal gonorrhea with substantial underscreening and the increased understanding of wide individual pharmacokinetic and pharmacodynamic variability has contributed to the recommendation for the increased ceftriaxone dose. i have gonorreah, i have been advised to take cefixime and azithromycin together. Presented at the National STD Prevention Conference, Atlanta, GA: September 14–24, 2020. The US CDC now recommends combination therapy with both IM ceftriaxone and azithromycin for gonorrhea, even if chlamydia is not diagnosed. The first dose is often a "double dose," twice as much as the remainder of the doses given. URL addresses listed in MMWR were current as of Workowski KA, Bolan GA; CDC. Data are limited regarding alternative regimens for treating gonorrhea among persons who have either a cephalosporin or IgE-mediated penicillin allergy. Sex Transm Dis 2013;40:877–9. For more information, see appropriate treatment sections under Gonoccocal Infections. Treatment with a single 1 g dose of azithromycin was compared to 100 mg doxycycline twice daily for seven days. DO NOT USE ceftriaxone or cefixime if Clinical use of ceftriaxone: a pharmacokinetic-pharmacodynamic perspective on the impact of minimum inhibitory concentration and serum protein binding. Silver nitrate and tetracycline ophthalmic ointment is no longer manufactured in the United States, bacitracin is not effective, and povidone iodine has not been studied adequately (582,583). 2. All isolates of suspected treatment failures should be sent to CDC for antimicrobial susceptibility testing by agar dilution; local laboratories should store isolates for possible further testing if needed. However, product inserts for each NAAT manufacturer must be carefully consulted because collection methods and specimen types vary. Sexually transmitted diseases treatment guidelines, 2010. Ocular prophylaxis is warranted because it can prevent sight-threatening gonococcal ophthalmia, has an excellent safety record, is easy to administer, and is inexpensive. N. gonorrhoeae causes ophthalmia neonatorum relatively infrequently in the United States (587). For preadolescent girls, vaginitis is the most common manifestation of this infection; gonococcal-associated PID after vaginal infection can be less common in preadolescents than adults. If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. The lowest ceftriaxone dose that was 100% effective at eradicating the susceptible organism (MIC = 0.008 μg/mL) 48 hours after treatment was 5 mg/kg body weight, which corresponded to an fT>MIC of 23.6 hours, consistent with the Monte Carlo simulation (18,19). For treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea, CDC recommends a single 500 mg IM dose of ceftriaxone (Box). Neissaria gonorrhoeae. We can no longer use cefixime … Please refer to the MMWR. Ceftriaxone concentrations tend to be more variable in the pharynx, and treatment of N. gonorrhoeae likely requires longer times above the strain’s MIC (21,22). Dombrowski JC, Wierzbicki MR, Newman L, et al. You will be subject to the destination website's privacy policy when you follow the link. Sexually transmitted infections (STIs) caused by the bacteria Neisseria gonorrhoeae (gonococcal infections) have increased 63% since 2014 and are a cause of sequelae including pelvic inflammatory disease, ectopic pregnancy, and infertility and can facilitate transmission of human immunodeficiency virus (HIV) (1,2). Investigators evaluated the efficacy of various ceftriaxone doses (0.06–30 mg/kg body weight). Erythromycin is the only antibiotic ointment recommended for use in neonates. The other is called azithromycin (Zithromax) and DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon. † https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitionsexternal icon. Rationale of Combination A new combination of cefixime and azithromycin is used for the treatment of upper and lower respiratory tract infection.Cefixime, an antibiotic, is a third-generation cephalosporin like ceftriaxone and cefotaxime. Neisseria gonorrhoeae is an important cause of sexually transmitted infections that can have severe reproductive health consequences. Gentamicin 240 mg IM as a single dose plus azithromycin 2 g po as a single dose -OR- Cefixime 800 mg orally as a single dose. There is another reason for using azithromycin in combination with ceftriaxone. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. Chlamydia seems rare to be transmitted through oral. Views equals page views plus PDF downloads. Specific microbiologic diagnosis of infection with N. gonorrhoeae should be performed in all persons at risk for or suspected to have gonorrhea; a specific diagnosis can potentially reduce complications, reinfections, and transmission. Combination therapy, using a highly effective gonococcal therapeutic agent with cotreatment for chlamydia, has been recommended since 1985. A test-of-cure at relevant clinical sites should be obtained 7–14 days after retreatment; culture is the recommended test, preferably with simultaneous NAAT and antimicrobial susceptibility testing of N gonorrhoeae if isolated. Wayne, PA: Clinical and Laboratory Standards Institute; 2020. For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered. Prevalence of, Yousfi K, Gaudreau C, Pilon PA, et al. No recent studies have been published on the treatment of DGI. In cases of suspected cephalosporin treatment failure, clinicians should obtain relevant clinical specimens for culture and antimicrobial susceptibility testing, consult an infectious disease specialist or STD clinical expert (https://www.stdccn.org/external icon) for guidance in clinical management, and report the case to CDC through state and local public health authorities within 24 hours. In 2012, cefixime was no longer a recommended gonococcal regimen (7), with ceftriaxone and azithromycin combination therapy the only recommended regimen for uncomplicated gonorrhea (5). For more information, see Gonococcal Infections in Adolescents and Adults. Saving Lives, Protecting People, https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions, https://www.cdc.gov/std/treatment-guidelines/evidence.htm, https://www.cdc.gov/std/stats18/STDSurveillance2018-full-report.pdf, https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf, https://clsi.org/media/3481/m100ed30_sample.pdf, https://www.cdc.gov/std/stats18/default.htm, https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm, Centers for Disease Control and Prevention, U.S. Department of Health & Human Services. Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely. If retesting at 3 months is not possible, clinicians should retest within 12 months after initial treatment. Specimens obtained from the conjunctiva, vagina, oropharynx, and rectum are useful for identifying the primary site(s) of infection. A murine model was used to estimate pharmacokinetic and pharmacodynamic parameters needed for cure at urogenital sites for both susceptible and resistant strains of N. gonorrhoeae (19). provided as a service to MMWR readers and do not constitute or imply Although dual drug therapy with different mechanisms of action (ceftriaxone and azithromycin) might have mitigated emergence of reduced susceptibility to ceftriaxone in N. gonorrhoeae, concerns regarding potential harm to the microbiome and the effect on other pathogens diminishes the benefits of maintaining dual therapy as the recommended treatment regimen. The pharynx tends to be screened less often (1) than other anatomic sites, and globally, most reported ceftriaxone-based regimen treatment failures have involved treatment of pharyngeal gonorrhea (20). The length of treatment will vary, depending on the type and severity of the infection. Providers should instruct patients to refer partners with whom they have had sexual contact in the past 60 days for evaluation, testing, and presumptive treatment (see Gonococcal Infection, Management of Sex Partners). Examination for clinical evidence of endocarditis and meningitis should be performed. One dose of ceftriaxone is adequate therapy for gonococcal conjunctivitis. If chlamydial infection has not been excluded, concurrent treatment with doxycycline (100 mg orally twice a day for 7 days) is recommended. I also saw on this site that another user was prescribed cipro 500mg and 1g azithromycin. § https://www.cdc.gov/std/treatment-guidelines/evidence.htm. the date of publication. Cefixime is highly stable in the presence of beta-lactamase enzymes. Detection of gonococcal infection in neonates who have sepsis, arthritis, meningitis, or scalp abscesses requires cultures of blood, CSF, and joint aspirate. Presumed gonococcal infection is established by documenting the presence of WBC containing intracellular purple diplococci in MB/GV smears. Sex Transm Infect 2007;83:304–9. Titles and abstracts were assessed, and 248 clinically relevant articles were reviewed. Nationally, the percentage of N. gonorrhoeae isolates with reduced susceptibility (MIC ≥2.0 μg/mL) increased more than sevenfold over 5 years (from 0.6% in 2013 to 4.6% in 2018) (Figure) (1). Ceftriaxone is a bactericidal third-generation cephalosporin with widely variable pharmacokinetics (17). EPT should cefixime and azithromycin combination dosage be considered a routine partner management strategy in MSM with gonorrhea because of a high risk for coexisting infections especially HIV infection and because no data exist on efficacy in this population. You have stated that you wish to take medication for your symptoms of gonorrhea and/or chlamydia. Performance standards for antimicrobial susceptibility testing. Because of its high specificity (>99%) and sensitivity (>95%), a Gram stain of urethral secretions that demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci can be considered diagnostic for infection with N. gonorrhoeae in symptomatic men. MIC, minimum inhibitory concentration. Dr. Jeff Livingston answered 22 years experience Obstetrics and Gynecology Signs of this infection include pain, foul-smelling … Otherwise, the partner may be treated with a single oral 800 mg cefixime dose plus oral doxycycline 100 mg twice daily for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia. Most suspected treatment failures in the United States are likely to be re-infections rather than actual treatment failures (86,480,481,577). Only parenteral cephalosporins (i.e., ceftriaxone) are recommended for use in children. RR-12). Positive Gram-stained smears of exudate, CSF, or joint aspirate provide a presumptive basis for initiating treatment for N. gonorrhoeae. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) PID can result in tubal scarring that can lead to infertility and ectopic pregnancy. However, cefixime does not provide as high, or as sustained, bactericidal blood levels as does ceftriaxone and demonstrates limited treatment efficacy for pharyngeal gonorrhea (27,28). endorsement of these organizations or their programs by CDC or the U.S. J Infect Dis 2016;214:1579–87. A test-of-cure is not needed for persons who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens; however, any person with pharyngeal gonorrhea who is treated with any regimen should return 7–14 days after treatment for a test-of cure using either culture or NAAT. If evidence of disseminated gonococcal infection exists, gonorrhea culture and antimicrobial susceptibility testing should be obtained from relevant clinical sites (see DGI). For more information, see Gonococcal Infections, Management of Sex Partners. However, be aware of the rising prevalence of tetracycline resistance among GISP isolates. Outdated information in this document has been redacted accordingly. Treatment failure should be considered in 1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period and 2) persons with a positive test-of-cure (i.e., positive culture >72 hours or positive NAAT ≥7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period (579). Macrolide resistance in MORDOR I—a cluster-randomized trial in Niger. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia. Culture remains the preferred method for diagnosing boys and for detecting infection in specimens obtained from extragenital sites regardless of gender (394). Doan T, Arzika AM, Hinterwirth A, et al. GISP monitors gonorrhea antimicrobial susceptibility patterns in the United States through monthly testing of urethral isolates from 25 symptomatic men in each of 25–30 STD specialty care clinics (1). MMWR Recomm Rep 2010;59(No. AND Empiric treatment for chlamydia is recommended for ALL patients treated for gonococcal infection regardless of chlamydia test results. Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s). During 2018, CDC staff members and subject matter experts identified essential questions regarding gonorrhea treatment to update the 2015 STD Treatment Guidelines (5). Atlanta, GA: US Department of Health and Human Services, CDC; 2019. Subgroups of MSM are at high risk for gonorrhea infection and should be screened at sites of exposure (see MSM). Based on review of recent evidence, CDC recommends a single 500 mg intramuscular dose of ceftriaxone for uncomplicated gonorrhea. Continuing to monitor for emergence of ceftriaxone resistance through surveillance and health care providers’ reporting of treatment failures will be essential to ensuring continued efficacy of recommended regimens. Many people who are infected with gonorrhea are also infected with chlamydia, another STI; azithromycin is effective in treating chlamydia. All children found to have gonococcal infections should be tested for C. trachomatis, syphilis, and HIV. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Cephalosporin MIC creep among gonococci: time for a pharmacodynamic rethink? Rather than signaling treatment failure, most of these infections result from reinfection caused by failure of sex partners to receive treatment or the initiation of sexual activity with a new infected partner, indicating a need for improved patient education and treatment of sex partners. Workowski KA, Berman S; CDC. Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., PID) have occurred. Availability of sensitive C. trachomatis nucleic acid amplification tests were widespread by 2010, but CDC recommended gonococcal dual therapy with a cephalosporin (ceftriaxone 250 mg IM or cefixime 400 mg orally) and either azithromycin or doxycycline (4) to reflect concerns regarding emerging gonococcal resistance. This preparation should be instilled into both eyes of all neonates as soon as possible after delivery, regardless of whether they are delivered vaginally or by cesarean section. No reliable alternative treatments are available for pharyngeal gonorrhea. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia. Some laboratories have met CLIA regulatory requirements and established performance specifications for using NAAT with rectal and oropharyngeal swab specimens that can inform clinical management. Perry TR, Schentag JJ. Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely. To identify isolates with elevated MICs, GISP uses the following “alert values” to identify potential emerging resistance: MIC ≥0.125 μg/mL for ceftriaxone, ≥0.25 μg/mL for cefixime, and ≥2 μg/mL for azithromycin (1). Results: Of 389 specimens reviewed, GC treatment failures occurred in 13 specimens treated with cefixime 400-mg single dose (17.8% treatment failure rate regardless of anatomical site) and in 1 oropharyngeal specimen treated with cefixime 800-mg single dose. Clinicians should consider the communities they serve and might opt to consult local public health authorities for guidance on identifying groups at increased risk. Uncomplicated infections are much more common, encompassing any Bachmann LH, Kirkcaldy RD, Geisler WM, et al. If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. • prevent transmission of gonorrhea TREATMENT OF CHOICE First Choice: • cefixime 800 mg PO in a single dose AND • azithromycin 1 gm po in a single dose OR • ceftriaxone 250 mg IM in a single dose AND • azithromycin 1 gm PO in a single dose Note: 1. Cefixime for oral suspension may be administered in the presence of impaired renal function. No data exist on the use of dual therapy to treat neonates born to mothers who have gonococcal infection. Gonorrhea may also raise the probability of contracting and transmitting HIV. Sexually Transmitted Disease Surveillance 2018. https://www.cdc.gov/std/stats18/default.htm. Sex Transm Dis 2009;36:478–89. Therapy for meningitis should be continued with recommended parenteral therapy for 10–14 days. 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