The correct answer is:

ceftriaxone plus azithromycin

Educational Objective:

Discuss treatment of a disseminated gonococcal infection in an adult.

Key Point:

This patient has disseminated gonococcemia (more specifically, the gonococcal arthritis-dermatitis syndrome), for which the 2015 guidelines of the Centers for Disease Control and Preventions (CDC) recommend hospitalization (at least initially), infectious disease consult, and ceftriaxone 1 gm IM or IV every 24 hours PLUS azithromycin 1 gm PO as a single dose. 

Explanation:

In 2020, the Centers for Disease Control and Prevention (CDC) published updated guidelines for the treatment of UNCOMPLICATED genital, rectal, and pharyngeal gonorrhea. The new recommendation is a single antibiotic regimen (ceftriaxone 500 mg IM single dose) rather than the former dual antibiotic regimen recommended in 2015 (ceftriaxone 250 mg IM single dose plus azithromycin 1g PO single dose). This change is due to increasing N. gonorrhoeae resistance to azithromycin. 

Caution: The CDC is currently working on new treatment guidelines for disseminated gonorrhea. However, for now the 2015 guidelines remain in force for disseminated gonorrhea (the above patient), with the recommended treatment continuing to consist of ceftriaxone 1 g IM or IV every 24 hours PLUS azithromycin 1g orally in a single dose. The 2015 guidelines also state that either cefotaxime or ceftizoxime may be substituted for ceftriaxone. For disseminated gonorrhea, any one of these 3 choices must continue to be combined with azithromycin.

Mostly, N. gonorrhoeae is resistant to fluoroquinolones and tetracyclines.  Occasionally, strains may be susceptible to penicillin G or amoxicillin, but either of these 2 choices should only be used after susceptibility testing has verified that the patient’s strain is susceptible (neither penicillin G nor amoxicillin should be started empirically). 

Treatment for coinfection with Chlamydia trachomatis with oral doxycycline (100 mg twice daily for 7 days) should be administered when chlamydial infection has not been excluded.

References:

Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64 (No 3): pgs 62-66. (updated June 5, 2015; note: these guidelines are still valid for disseminated gonorrhea, but no longer for uncomplicated gonorrhea) (Accessed July 13, 2021).

Centers for Disease Control and Prevention (CDC). Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. (Updated December 18, 2020) (Accessed July 12, 2021)