[Question #5686] Gonorrhea and ceftriaxone effectiveness

21 months ago

Dear Dr, I recently posted a question, on HIV prevention category, of my case concerned with HIV which was greatly responded by Dr.E.Hook. Nonetheless, now I have some concern regarding gonorrhea and as the thread was already closed I got embarrassed posting there again and I’m making other thread but same history(sorry opening 2 threads in short time):

11 days ago I performed unprotected vaginal sex. 2 to 3 days after I started having discharge in penis. Dr diagnosed Chlamydia and treated with azithromycin 1g+levofloxacin 750mg. 1 week after taking antibiotics the discharge continued and became more yellow/yellowish. I went to other doctor more specialist for STD and as soon as he looked the discharge He diagnosed gonorrhea (unfortunately didn’t think testing was necessary) and treated with shot of ceftriaxone 500mg. Doctor said ceftriaxone would act very fast and symptoms should go away on the day after. I took it 07/10 @night, today 07/12 morning I still got discharge (less, but little more thicker i think). Tingling when urinating has stoped for the time being though.

As all this episode has distressed me a lot, and also got frustrated with first treatment (azi 1g + levo750mg) failure, I’m worried ceftriaxone might not be killing the bug as I still have discharge and doctor said it would act very fast

1 - how long after ceftriaxone should symptoms go away? Specially discharge

2 - how long should I wait (if discharge keep coming) to get back to clinic?

3 - isn’t ceftriaxone 500mg virtually 100% effective for gonorrhea? If discharge continue should I be sure I have other thing besides gonorrhea?

4 - if is indeed only gonorrhea and the ceftriaxone fails, what should be next step?

Please advise.

Thanks again!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Welcome back. I reviewed your discussion with Dr. Hook and agree with all he advised. I too would strongly reassure you about HIV. Although you should have a conclusive AgAb (4th generation) HIV blood test in a few weeks, you can definitely expect a negative result.

Most likely you had gonorrhea from the start of your symptoms. Although the discharge in gonorrhea typically is thick and yellowish (it's pus, basically), it's often thinner and more watery in the first 2-3 days. In other words, early gonorrhea can look just like a typical chlamydial infection. Ideal management at the start would have been to treat you at the outset with both ceftriaxone (not levofloxacin) and azithromycin, covering both gonorrhea and chlamydia. Many gonorrhea strains these days are resistnat to levofloxacin and other drugs in its class (called quinolones), and they are no longer recommended. That your discharge became more prominent afterr a few days, despite treatment with azithromycin and levofloxacin is strong evidence of gonorrhea resistance to both those antibiotics.

Ceftriaxone, however, remains 100% reliable (assuming a standard dose of 250 mg -- and 500 mg is of course equally reliable). And it sounds like your improvement is on track. Gonorrhea symptoms never clear up entirely in a day or two. By 1-2 days there should be reduced discharge and less painful urination. I expect your symptoms to continue to improve over the next few days and probably will be entirely gone in 5-7 days. If still any problems at 10 days, that's when to consider another round of exam and testing. (If no improvement at all, you could return to the clinic on Monday. But I'm confident they'll improve rapidly from here on out.

Those comments directly cover all four of your numbered questions. Let me know if anything isn't clear.

Oh, one more thing:  what does your partner know about all this? Has she been informed and treated? If not, or if you're unsure, you have a responsibility to let her know, if you are able. If not, the local health department may be able to help.

HHH, MD
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21 months ago
Dear Dr Handsfield, many thanks for the fast reply. I’ll post a follow up in the next few days of how was the outcome.
Regarding my partner, I let her know, and after the fact she did blood exams (all negative including HIV) and exams that visually check uterus and take secretions of woman genital and reproductive system for lab check covering chlamydia and gonorrhea but takes 1+week for results. Even though she has no apparent symptoms her gynecologist  treated her with azithromycin 1g + ciprofloxacin 500mg twice/day for 7 days.
Thanks! I’ll let you know the outcome.
21 months ago
Just to be clear! I’m single, the “partner” I was referring was the girl herself that I had the unprotected sex with and got the gono after. I don’t have wife or girlfriend I should inform the fact!
Thanks 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
I knew which partner you were referring to. I'm glad to hear she has been treated, but she has been given the same sort of unreliable regimen you were. Ciprofloxacin is a quinolone, and since levofloxacin didn't cure your gonorrhea, it won't cure her. She needs ceftriaxone in addition to the azithromycin.

You must be somewhere outside the US, I'm guessing. Almost nobody is using quinolones in this country, and they shouldn't be used anywhere else either.
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21 months ago
Sorry keep replying, but I think this information may be interesting to you as specialist/research. I’m from Brazil.
That’s why I’ve went to 2nd doctor... the first one after the failure of azi+Levo wanted to prescribe me 14days of doxycyclin. In a very fast research on google I figured out it doesn’t treat gonorrhea, only chlamydia. But this was a doctor’s flaw or outdated, not a general guideline problem here, because after research found out that indeed Brazilian national health ministry guidelines recommends ceftriaxone 500mg + 1g azithromycin for my case!
Regarding my partner, I don’t want to contradict her doctor on the middle of treatment, but for sure if she doesn’t get cured I’ll let her know ceftriaxone is the most appropriate.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Actually, doxycycline often is effective against gonorrhea, but it depends on whether tetracycline-resistant strains are common in a particular geographic area. In other words, like the quinolones, it might be effective, but not reliably so. The official guidelines from the health mninistry are good, indeed ahead of the US. It is possible that CDC will change the US recommendation for ceftriaxone from 250 to 500 mg. We'll know in a few months.

Most gonorrhea and chlamydia in women causes no symptoms. Even if she has symptoms, if they clear up, it won't necessarily mean she is cured. In my opinion, it would be a kindness to tell her what you now know, that ciprofloxacin isn't reliable and that ceftriaxone is recommended for gonorrhea. She can then be the one to decide what to say to her doctor, if anything. That's what I would do if somehow I were in your situation.
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21 months ago
Thanks! I’ll follow your recommendation and tell her.
Only one correction, to be fully accurate, the Brazilian guidelines here for genital gonorrhea are:

Ceftriaxone 500mg + azithromycin 1g
OR
ciprofloxacin* 500mg(single dose)+ azithromycin 1g

*for 18yr minors and pregnant women they state ciprofloxacin is not recommended
Also it is listed some states (and my state is included) of Brazil stating for these areas the ciprofloxacin treatment is not recommended due to 5%+ of gonorrhea strains are resistant.

That’s it, I know here is limited posts, won’t post more until finish treatment and let you now the outcome! Thanks
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Interesting. It seems likely that the ministry is carefully following trends in gonorrhea quinolone resistance, but i wouldn't guarantee it, and would be surprised if at least 5% of strains are resistant. Almost no other countries, whether devloping or industrialized, have such low levels of quinolone resistance. And it is virtually 100% certain you, and thus your partner, were infected with a quinolone resistant strain.

No more comments or advice until/unless you have more test results or other outcomes to report.
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21 months ago

Dear Dr,

Today morning has been 4 and 1/2 days from ceftriaxone500mg, and still have yellowish discharge. Much less than before medicine but it is the same reduced amount that I got from the day after ceftriaxone (reduced around 70/80%)

I’m aware you told it would be reducing progressively until 5-7 days, the problem is I don’t see a gradual reduction day by day... it’s the same little tear/drop that comes every morning (70-80% less than before medicine)... and little secretion at night (less than a tear)

Shouldn’t be wise ask clinic today for a reinforce on medication? 

I saw ceftriaxone half life is very short, Is it still working at my body or this discharge days after medicine is something residual with bacteria already dead?

Normally I would be more patient, but I’m all booked for vacation next week Wednesday and I must be sure I don’t have gonorrhea by there to travel. 

Thanks!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Yes, it seems reasonable for you to be reevaluated in person, to include retesting for both gonorrhea and chlamydia, and preferably trichomonas -- and Mycoplasma genitalium, if such testing is available. If not, they may decide you should be treated for trichomonas (metronidazole or tinidazole) and M. genitalium (moxofloxacin).

Ceftriaxone half life is 8-10 hours, which is not short -- indeed rather long. It is conceivable you have persistent gonorrhea due to ceftriaxone failure, but this is exceedingly rare and not a likely explanation for continuing discharge. However, it should be considered when you are reexamined. I would encourage your doctor or clinic to test you for gonorrhea not only by nucleic acid testing (NAAT) but also by culture (to grow the bacteria), which would make it easy to test for antibiotic resistance.

All this needs in-person care, and we do not provide direct medical care on this forum, and that will have to end this discussion. Please don't start a new thread until and unless the problem has been entirely resolved by direct medical care. We really will not be able to comment any more, at least not meaningfully, until then. Good luck with it all.
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