Gonorrhea

Published on 18/03/2015 by admin

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Gonorrhea

Jacqueline A. Guidry and Ted Rosen

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Gonorrhea is a common and potentially severe sexually transmitted disease caused by the Gram-negative aerobic diplococcus Neisseria gonorrhoeae. This organism primarily infects the mucous membranes of the urethra, endocervix, rectum, and pharynx. The disease can also become disseminated, causing petechial or acral pustular skin lesions, tenosynovitis, arthralgia, true septic arthritis, perihepatitis, and less commonly endocarditis or meningitis. Dissemination is more common in women. Conversely, the infection may be asymptomatic.

Management strategy

Individuals with gonorrhea should be treated as promptly as possible: (a) to prevent regional infection such as epididymitis or pelvic inflammatory disease leading to infertility or ectopic pregnancy; (b) to prevent disseminated gonococcal infection, which occurs in about 1–3% of cases; and (c) to stop transmission to sexual partners. Prompt management has become especially important due to resurgence in incidence of gonococcal disease in the US and increasing antimicrobial resistance worldwide.

Gonococcal urethritis is typically characterized by mucopurulent to frankly purulent discharge along with a burning sensation during urination. In the absence of discharge, dysuria may be the only symptom.

Gonococcal cervicitis is characterized by a mucopurulent or purulent endocervical exudate. However, a cervical discharge is not specific for a gonococcal infection, and gonococcal infection of the cervix is often asymptomatic.

Pharyngeal infection is asymptomatic in more than 90% of cases.

Rectal infection is prevalent in homosexual men, causing anal discharge and pain. In women, rectal infection results from spread through vaginal secretions and does not necessarily imply anal intercourse.

Patients in whom gonorrhea is suspected should be investigated using the most sensitive and specific tests, though empiric treatment of the symptoms may be recommended for patients at high risk for infection who are deemed unlikely to return for a follow-up evaluation.

Patients infected with N. gonorrhoeae are often co-infected with Chlamydia trachomatis and should be treated with azithromycin or doxycycline to cover this organism, with or without diagnostic evidence of chlamydial disease. Patients with gonorrhea should be tested for both syphilis and HIV.

Patients should be instructed to return for evaluation if symptoms persist or recur after therapy, and to abstain from sexual intercourse until they and their sexual partners are cured. Because re-infection is so common, the CDC recommends that all patients with known gonorrhea return for re-testing 3 months post-treatment. A test-of-cure 3 to 4 weeks post-treatment is no longer recommended.

Antimicrobial resistance is a real threat and treatment options for gonococcal disease are increasingly limited. To abate further spread of resistant strains of N. gonorrhoeae, physicians should strongly encourage patient referral of any sexual partner within the preceding 60 days for evaluation and treatment, and obtain culture(s) to evaluate individual antimicrobial susceptibility in any patient whose symptoms do not resolve with initial treatment.

Specific investigations

First-line therapies

imageCeftriaxone 250 mg intramuscularly in a single dose + azithromycin 1 g orally B
imageCeftriaxone 250 mg intramuscularly in a single dose + doxycycline 100 mg twice daily for seven days B
imageCefixime 400 mg orally in a single dose + azithromycin 1 g orally B
imageCefixime 400 mg orally in a single dose + doxycycline twice daily for seven days B

Second-line therapies

imageCefopodoxime 400 mg orally in a single dose C
imageCefuroxime 1 g orally in a single dose B

Third-line therapies

imageAzithromycin 2 g orally in a single dose C
imageSpectinomycin 2 g intramuscularly in a single dose B
imageCiprofloxacin 500 mg orally in a single dose B
imageOfloxacin 400 mg orally in a single dose B
imagePenicillin 8 x 106 units intramuscularly plus 1 g of probenecid B
imageGentamicin 240 mg intramuscularly as a single dose B

Special considerations

Pharyngeal infection

Pregnancy

Treatment of gonorrhoea in pregnancy.

Cavenee MR, Farris JR, Spalding TR, Barnes DL, Castaneda YS, Wendel GD Jr. Obstet Gynecol 1993; 81: 33–8.

A randomized study on 250 cases comparing ceftriaxone 250 mg intramuscularly, spectinomycin 2 g intramuscularly, and amoxicillin 3 g orally with probenecid 1 g showed efficacy was 95%, 95%, and 89%, respectively. There was no increase in congenital malformations. Ceftriaxone and spectinomycin are the best choices. Pregnant women should not be treated with quinolones or tetracyclines. (Comment: Since spectinomycin is no longer available in the US, ceftriaxone is the default drug of choice.)

Pregnant women who cannot tolerate a cephalosporin should receive azithromycin 2 g in a single dose. They should also be treated for coexisting chlamydial infection with azithromycin or amoxicillin.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Gonorrhea

Jacqueline A. Guidry and Ted Rosen

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Gonorrhea is a common and potentially severe sexually transmitted disease caused by the Gram-negative aerobic diplococcus Neisseria gonorrhoeae. This organism primarily infects the mucous membranes of the urethra, endocervix, rectum, and pharynx. The disease can also become disseminated, causing petechial or acral pustular skin lesions, tenosynovitis, arthralgia, true septic arthritis, perihepatitis, and less commonly endocarditis or meningitis. Dissemination is more common in women. Conversely, the infection may be asymptomatic.

Management strategy

Individuals with gonorrhea should be treated as promptly as possible: (a) to prevent regional infection such as epididymitis or pelvic inflammatory disease leading to infertility or ectopic pregnancy; (b) to prevent disseminated gonococcal infection, which occurs in about 1–3% of cases; and (c) to stop transmission to sexual partners. Prompt management has become especially important due to resurgence in incidence of gonococcal disease in the US and increasing antimicrobial resistance worldwide.

Gonococcal urethritis is typically characterized by mucopurulent to frankly purulent discharge along with a burning sensation during urination. In the absence of discharge, dysuria may be the only symptom.

Gonococcal cervicitis is characterized by a mucopurulent or purulent endocervical exudate. However, a cervical discharge is not specific for a gonococcal infection, and gonococcal infection of the cervix is often asymptomatic.

Pharyngeal infection is asymptomatic in more than 90% of cases.

Rectal infection is prevalent in homosexual men, causing anal discharge and pain. In women, rectal infection results from spread through vaginal secretions and does not necessarily imply anal intercourse.

Patients in whom gonorrhea is suspected should be investigated using the most sensitive and specific tests, though empiric treatment of the symptoms may be recommended for patients at high risk for infection who are deemed unlikely to return for a follow-up evaluation.

Patients infected with N. gonorrhoeae are often co-infected with Chlamydia trachomatis and should be treated with azithromycin or doxycycline to cover this organism, with or without diagnostic evidence of chlamydial disease. Patients with gonorrhea should be tested for both syphilis and HIV.

Patients should be instructed to return for evaluation if symptoms persist or recur after therapy, and to abstain from sexual intercourse until they and their sexual partners are cured. Because re-infection is so common, the CDC recommends that all patients with known gonorrhea return for re-testing 3 months post-treatment. A test-of-cure 3 to 4 weeks post-treatment is no longer recommended.

Antimicrobial resistance is a real threat and treatment options for gonococcal disease are increasingly limited. To abate further spread of resistant strains of N. gonorrhoeae, physicians should strongly encourage patient referral of any sexual partner within the preceding 60 days for evaluation and treatment, and obtain culture(s) to evaluate individual antimicrobial susceptibility in any patient whose symptoms do not resolve with initial treatment.

Specific investigations

A laboratory-based evaluation of the BioStar Optical ImmunoAssay point-of-care test for diagnosing Neisseria gonorrhoeae infection.
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