Table 1.

Treatment guidelines for gonococcal infection in adults^{2,5,11,12,20,21}

Guidelines	Anogenital infection*	Pharyngeal infection
Public Health Agency of Canada: Recommendations for Gonorrhea Treatment 2013†	Preferred‡: Ceftriaxone 250 mg IM as a single dose plus azithromycin§ 1 g PO as a single dose Cefixime 800 mg PO as a single dose plus azithromycin 1 g PO as a single dose (not preferred in men who have sex with men)	Preferred: Ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g PO as a single dose
	Alternatives: Spectinomycin** 2 g IM as a single dose plus azithromycin 1 g PO as a single dose Azithromycin 2 g PO as a single dose††	Alternatives: Cefixime 800 mg PO as a single dose plus azithromycin 1 g PO as a single dose Azithromycin 2 g PO as a single dose
Public Health Ontario: Recommendations for Gonorrhea Treatment 2013	Preferred: Ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g PO as a single dose	Preferred: Ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g PO as a single dose
	Alternatives: Cefixime 800 mg PO as a single dose plus azithromycin 1 g PO as a single dose Spectinomycin 2 g IM as a single dose plus azithromycin 1 g PO as a single dose Azithromycin 2 g PO as a single dose	Alternatives: Cefixime 800 mg PO as a single dose plus azithromycin 1 g PO as a single dose Spectinomycin 2 g IM as a single dose plus azithromycin 1 g PO as a single dose Azithromycin 2 g PO as a single dose
Quebec (INESSS): Infection à Neisseria gonorrhoeae 2013	Preferred: Cefixime 800 mg PO as a single dose plus treatment against Chlamydia trachomatis Ceftriaxone 250 mg IM as a single dose plus treatment against C. trachomatis, that is, azithromycin 1 g PO as a single dose	Preferred: Ceftriaxone 250 mg IM as a single dose plus treatment against C. trachomatis, that is, azithromycin 1 g PO as a single dose
Update to CDC Guidelines 20122	Preferred: Ceftriaxone 250 mg IM as a single dose plus either azithromycin 1 g PO as a single dose or doxycycline 100 mg PO bid × 7 days	Preferred: Ceftriaxone 250 mg IM as a single dose plus either azithromycin 1 g PO as a single dose or doxycycline 100 mg PO bid × 7 days
	Alternatives (if ceftriaxone not available): Cefixime 400 mg PO as a single dose plus either azithromycin 1 g PO as a single dose or doxycycline 100 mg PO bid × 7 days Azithromycin 2 g PO as a single dose
European Guidelines 2012	Preferred: Ceftriaxone 500 mg IM as a single dose plus azithromycin 2 g PO as a single dose	Preferred: Ceftriaxone 500 mg IM as a single dose plus azithromycin 2 g PO as a single dose
	Alternatives: If ceftriaxone is not available or injection cannot be administered—e.g., patient refuses: Cefixime 400 mg PO as a single dose plus azithromycin 2 g PO as a single dose If azithromycin not available or patient unable to swallow azithromycin:	Alternatives: If azithromycin not available or patient unable to swallow azithromycin: Ceftriaxone 500 mg IM as a single dose If history of cephalosporin or penicillin (severe) allergy and if N. gonorrhoeae known to be quinolone-sensitive:
	Ceftriaxone 500 mg IM as a single dose If possible/known resistance or allergy to extended spectrum cephalosporins: Spectinomycin 2 g IM as a single dose plus azithromycin 2 g PO as a single dose	Ciprofloxacin 500 mg PO as a single dose or ofloxacin 400 mg PO as a single dose If history of cephalosporin or penicillin (severe) allergy: Azithromycin 2 g PO as a single dose
UK National Guidelines (BASHH) 2011	Preferred: Ceftriaxone 500 mg IM as a single dose plus azithromycin 1 g PO as a single dose	Preferred: Ceftriaxone 500 mg IM as a single dose plus azithromycin 1 g PO as a single dose If sensitive to quinolones: Ciprofloxacin 500 mg PO as a single dose or ofloxacin 400 mg PO as a single dose Note: Spectinomycin has poor efficacy in pharyngeal infections.
	Alternatives (if IM contraindicated or patient refuses): Cefixime 400 mg PO as a single dose Spectinomycin 2 g IM as a single dose Cefotaxime 500 mg IM as a single dose Cefoxitin 2 g IM as a single dose plus probenecid 1 g PO as a single dose Cefpodoxime 200 mg PO as a single dose If sensitive to quinolones: Ciprofloxacin 500 mg PO as a single dose or ofloxacin 400 mg PO as a single dose Azithromycin 2 g PO as a single dose

^*Anogenital sites include urethral, rectal, vaginal and endocervical.

^†The Public Health Agency of Canada’s guidelines are for adults and youth 9 years of age and older.

^‡First-line recommendations are listed as preferred regimens and second-line recommendations are listed as alternatives. The order of appearance does not suggest a preference for one particular regimen over another.

^§Azithromycin is preferred over doxycycline due to high rates of resistance to tetracyclines and concern about compliance.

^**Spectinomycin is available only through Health Canada’s Special Access Program.

^††Azithromycin at a dose of 2 g is associated with significant gastrointestinal adverse effects that can be minimized if taken with food or with use of antiemetic prophylaxis. If vomiting occurs within 1 hour of administration, the dose of azithromycin should be repeated.