This protocol addresses gonococcal proctitis in individuals who are pregnant or breast/chest feeding and in whom standard first-line therapy has not achieved the required clinical and microbiological endpoints, indicating likely drug-resistant infection.
Pregnant and breast/chest-feeding individuals require careful agent selection. Quinolones must not be used in this population. Gentamicin should also be avoided during pregnancy. These restrictions substantially narrow the options available when first-line treatment has not succeeded.
First-line treatment with ceftriaxone did not meet the endpoints required to confirm success: resolution of rectal symptoms (anal discharge, perianal or anal pain) and a negative NAAT test of cure for Neisseria gonorrhoeae performed at least two weeks after treatment. This protocol is the next step when those endpoints are not reached.
Where ceftriaxone-resistant (multi-drug resistant) infection is confirmed, a carbapenem-class antibiotic is among the options considered — with agent selection and management guided by antimicrobial susceptibility testing results and specialist expert advice. The complete regimen is available in the full protocol.
DOI: 10.1177/09564624251345195
Pregnant and breast/chest-feeding individuals should not be treated with quinolones.
Gentamicin should be avoided in pregnancy.
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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