Gonococcal pharyngitis caused by multi-drug resistant (MDR) N. gonorrhoeae presents a management challenge when standard first-line therapy has not achieved microbiological clearance. A defined escalation pathway, guided by susceptibility data and specialist input, is available for this situation.
The previous line of treatment — ceftriaxone-based therapy — is considered to have failed when the test of cure remains positive. Specifically, failure is defined as the patient not being negative for N. gonorrhoeae at 12 days following treatment, or a NAAT performed at least two weeks after treatment returning a positive result. Non-achievement of this microbiological clearance endpoint is the trigger for escalation to this protocol.
Resolution of pharyngeal infection confirmed by a negative test of cure: no isolation of N. gonorrhoeae by culture and a negative NAAT.
Some infections with MDR N. gonorrhoeae have been successfully treated with ertapenem when ceftriaxone has failed; three days of IV ertapenem 1 g was used for these cases, although this was a pragmatic choice and not guided by clinical trial data.
In a recent RCT, a single 1 g dose of ertapenem IM was noninferior to ceftriaxone 500 mg IM, although all strains were susceptible to ceftriaxone and had low ertapenem MICs.
Those with pharyngeal infection should be negative 12 days following treatment.
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