The mainstay of treatment is the appropriate use of antibiotics. While penicillin was the most common antibiotic used to treat gonorrhea up until the 1970s, an increase in antibiotic resistance has led to a decline in its use. Recommendations for first choice treatment of gonorrhea must therefore depend on local information on resistance patterns and it is not possible to make treatment recommendations that are applicable to all parts of the world.

Antibiotics that may be used to treat gonorrhea include:

• Cefixime 400 mg orally
• Ceftriaxone (Rocephin) 125 to 250 mg by intramuscular injection
• Cefotaxime 500 mg by intramuscular injection
• Cefpodoxime (Vantin) 400 mg orally
• Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally
• Ciprofloxacin 500 mg orally
• Ofloxacin 400 mg orally
• Levofloxacin 250 mg orally
• Azithromycin 2 g orally
• Spectinomycin 2 g by intramuscular injection
• Amoxycillin 2 g plus probenecid 1 g orally
• Ampicillin 2 to 3 g plus probenecid 1 g orally

These drugs are all given as a single dose.

The level of tetracycline resistance in Neisseria gonorrheae is now so high as to make it completely ineffective in most parts of the world.

The fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) cannot be used in pregnancy.It is important to refer all sexual partners to be checked for gonorrhea to prevent spread of the disease and to prevent the patient from becoming re-infected with gonorrhea. Patients should also be offered screening for other sexually transmitted infections. In areas where co-infection with chlamydia is common, doctors may prescribe a combination of antibiotics, such as ceftriaxone with doxycycline or azithromycin, to treat both diseases.

Penicillin is ineffective at treating rectal gonorrhea: this is because other bacteria within the rectum produce β-lactamases that destroy penicillin. All current treatment are less effective at treating gonorrhea of the throat, so the patient must be rechecked by throat swab 72 hours or more after being given treatment, and then retreated if the throat swab is still positive.

Although, gonorrhea usually does not require follow-up (with the exception of rectal or pharyngeal disease), patients are usually advised to phone for results 5 to 7 days after diagnosis to confirm that the antibiotic they received was likely to be effective. Patients are advised to abstain from sex during this time.

US recommendations

The US does not have a federal system of sexual health clinics, and the majority of infections are treated in family practices.A third-generation cephalosporin antibiotic such as ceftriaxone is recommended for use in most areas. Some areas such as Hawaii and California, have very high levels of resistance to fluoroquinolone antibiotics (ciprofloxacin, ofloxacin, levofloxacin) they are no longer used empirically to treat infections originating in these areas.

UK recommendations

In the UK, the majority of patients with gonorrhea are treated in dedicated sexual health clinics.The current recommendation is for ceftriaxone or cefixime as first line therapy; no resistance to either drug has yet been reported in the UK. Levels of spectinomycin resistance in the UK are less than 1%, which would make it a good choice in theory, but intramuscular spectinomycin injection is very painful.

Azithromycin (given as a single dose of 2 g) is recommended if there is concurrent infection with chlamydia.A single dose of oral ciprofloxacin 500 mg is effective if the organism is known to be sensitive, but fluoroquinolones were removed from the UK recommendations for empirical therapy in 2003 because of increasing resistance rates. In 2005, resistance rates for ciprofloxacin were 22% for the whole of the UK (42% for London, 10% for the rest of the UK).[10]