KEG: Why is Ceftriaxone 250mg IM still preferred over Cefixime 800mg po? Patients don't like needles and the IM dosing takes up more nursing time.

Dr. Ameeta Singh: Here are the current Alberta guidelines for treatment of gonorrhea (2021):

Heterosexual Adults/Pregnant Women (urethral, cervical, rectal infection)

Preferred cefixime 800 mg PO as a single dose (A-I) PLUS azithromycin 1g PO as a single dose (BII)

Alternate ceftriaxone 250 mg IM as a single dose (A-I) PLUS azithromycin 1 g PO as a single dose (BII) OR (not recommended in pregnancy) azithromycin* 2 g PO as a single dose (AI) PLUS gentamicin≠ 240 mg IM in 2 separate 3-mL injections of 40 mg/mL solution (B-II) OR (not recommended in pregnancy) azithromycin* 2 g PO as a single dose (A-I) PLUS gemifloxacin# 320 mg PO in a single dose (B-II)

Men who have sex with men (MSM) or Pharyngeal infections

Preferred ceftriaxone 250 mg IM as a single dose (A-I) PLUS azithromycin 1 g PO as a single dose (BII), (B-III for pharyngeal infections)

Alternate cefixime 800 mg PO as a single dose (A-l for MSM, B-III for pharyngeal infections) PLUS azithromycin 1 g PO as a single dose (B-II for MSM), (B-III) for pharyngeal infections OR (not recommended in pregnancy) azithromycin* 2 g PO as a single dose (AI) PLUS gentamicin≠ 240 mg IM in 2 separate 3 - mL injections of 40 mg/mL solution (B-II)

OR (not recommended in pregnancy) azithromycin* 2 g PO as a single dose (A-I) PLUS gemifloxacin# 320 mg PO in a single dose (BII) * Since azithromycin resistance has been reported, this agent should not be used as monotherapy. ≠ Gentamicin 240 mg IV infused over 30 minutes may be considered as an alternative route of administration when the IM route is not feasible. # At the time of printing of these guidelines, gemifloxacin is not available in Canada but has been included due to the potential for future availability.

Bottomline:

Cefixime can be used for heterosexual, non pharyngeal gonococcal infections as the resistance rates to cefixime is lower among heterosexual persons. Cefixime is generally not recommended for pharyngeal infections as inadequate levels of the drug are achieved in the pharynx.