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Posted on: February 18, 2021

Clinician Advisory: Updated Guidelines for Gonorrhea & Syphilis February 18, 2021

Clinician Advisory
Updated Guidelines for Gonorrhea & Syphilis
February 18, 2021

Gonorrhea Treatment Update

Requested action:

Please note and implement these updated recommendations for the treatment of uncomplicated gonococcal infections of the urogenital tract, rectum, and pharynx:

table health alert 021821

  • Anti-chlamydia co-treatment: if concurrent chlamydial infection has not been excluded, add one of the following:
    • doxycycline 100mg po bid x 7d; or
    • azithromycin 1gm po in a single dose (e.g., pregnancy, adherence or tolerance concerns); or
    • azithromycin 2gm po in a single dose (e.g., cefixime used rather than ceftriaxone and pharyngeal gonorrhea has not been excluded).
  • Test-of-cure (7-14 days after treatment with NAAT or culture) is only recommended for
    • pharyngeal cases, or
    • cases treated with an agent other than ceftriaxone.
  • Test all gonorrhea cases for re-infection at 3 months.
  • Partner treatment for gonorrhea exposure:
    • cefixime 800 mg po in a single dose, PLUS
    • azithromycin 2gm po in a single dose.

Note: This combination will be the standard partner “pack #2” for dispensing of state-subsidized expedited partner therapy (EPT) of gonorrhea contacts.



  • In 2020, 793 cases of gonorrhea were reported to the Health District, not substantially different than the 764 reported in 2019.
  • CDC’s change in treatment of cases from dual therapy (ceftriaxone 250mg IM + azithromycin 1gm PO) to monotherapy (ceftriaxone 500mg IM) was prompted by three considerations:
    • antimicrobial stewardship and the need to minimize antibiotic exposure unless the benefit clearly outweighs the risk, an important consideration for all infections and not just STIs;
    • further evidence and understanding of ceftriaxone’s pharmacokinetics and pharmacodynamics inrelation to identifying the optimal dose to treat gonorrhea; and
    • signs that azithromycin resistance is increasing.
  • The Washington State Department of Health’s preference for anti-chlamydia coverage with azithromycin 2gm (rather than azithromycin 1gm or doxycycline 100mg po bid x 7d) is based on the following considerations:
    • doxycycline has not yet been studied for expedited partner therapy and has more side effects than azithromycin (e.g., esophagitis, photosensitivity);
    • assessment for pregnancy is difficult and prone to error in the EPT setting; and
    • azithromycin 2gm is effective at clearing pharyngeal gonorrhea. 


Prevention of Congenital Syphilis

Requested actions:

  • Treat all patients with signs or symptoms consistent with primary or secondary syphilis when they present for care.
  • Routinely conduct serologic screening for syphilis among
    • pregnant women for syphilis at their first prenatal visit and again with routine 3rd trimester labs (e.g., 24-28 weeks) and
    • other patients who are sexually active and
      • homeless, or
      • exchanging money or drugs for sex, or
      • using heroin, methamphetamine or cocaine.


Reported cases of syphilis for 2019-2020 were as follows:

table 2 health alert 021821

  • The syphilis epidemic in Washington state over the past 20 years has predominantly affected men who have sex with men. However, in recent years the number of cases among heterosexuals has increased five-fold statewide. Also increasing is the number of syphilis cases among homeless individuals, particularly in adjacent King County where about half the homeless cases identify as heterosexual. As cases among heterosexuals have risen in recent years, congenital syphilis has resurged from the brink of elimination. Congenital syphilis can result in miscarriage, neonatal death, pre-term delivery and long-term health problems in children. Most cases of congenital syphilis arise among women who did not present for pre-natal care or who acquired the infection after first trimester testing.
  • Consequently, The Washington State Department of Health recommends adding an early third trimester test for syphilis among pregnant women presenting for care.

STD Control Consultation & Logistics

For consultation on management of STD cases, to obtain STD case report forms, or to learn more about expedited partner therapy for gonorrhea and chlamydia, call 425-339-5261 or fax 425-339-8707.

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