Gonococcal Proctitis When Ceftriaxone Treatment Has Failed
This protocol addresses gonococcal proctitis in the setting of confirmed treatment failure — where a ceftriaxone-based first-line regimen has not achieved the expected clinical and microbiological outcomes, and multidrug-resistant infection is suspected or confirmed.
Previous treatment failure
First-line therapy — ceftriaxone as a single intramuscular dose (with alternatives such as cefixime, gentamicin, azithromycin, or ciprofloxacin where clinically indicated) — did not achieve the required treatment goals.
Goals not reached: resolution of rectal symptoms (anal discharge, perianal or anal pain), and a negative nucleic acid amplification test (NAAT) for Neisseria gonorrhoeae performed at least two weeks after treatment.
Next-line approach
When susceptibility testing confirms ceftriaxone-resistant (multidrug-resistant) infection, management is guided by antimicrobial susceptibility results and specialist input. A carbapenem-class agent is among the options considered — the complete regimen, route, and clinical pathway are available in the full protocol.
References
DOI: 10.1177/09564624251345195
- 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.
- Treatment options are limited and should be guided by the results of antimicrobial susceptibility testing where possible, and in conjunction with expert advice.
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