- What is gonorrhea
- How do you get gonorrhea?
- Is gonorrhea curable?
- Gonorrhea prevention
- Gonorrhea signs and symptoms
- Gonorrhea complications
- Gonorrhea diagnosis
- Gonorrhea treatment
- Antibiotics for gonorrhea
- Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum
- Uncomplicated Gonococcal Infections of the Pharynx
- Gonococcal conjunctivitis
- Disseminated Gonococcal Infection
- Gonococcal Infections in Pregnancy
- Management of Antibiotic-Resistant Gonorrhea
- Allergy to Penicillins or Cephalosporin
- Management of Suspected Gonococcal Treatment Failure
- Management of Sex Partners
- Antibiotics for gonorrhea
What is gonorrhea
Gonorrhea also known as ‘the clap’, is a sexually transmitted disease (sexually transmitted infection). Gonorrhea is most common in young adults. The bacteria Neisseria gonorrhoeae (gonorrhea) that cause gonorrhea can infect the genital tract, the urethra (the tube for urine), cervix (the opening of the uterus at the top of the vagina), mouth, throat, eyes or anus. You can get gonorrhea during vaginal, oral, or anal sex with an infected partner. A pregnant woman can pass it to her baby during childbirth.
Gonorrhea does not always cause symptoms. In men, gonorrhea can cause pain when urinating and discharge from the penis. If untreated, it can cause problems with the prostate and testicles, causing permanent damage and infertility in men and women
In women, the early symptoms of gonorrhea often are mild. Later, it can cause bleeding between periods, pain when urinating, and increased discharge from the vagina. If untreated, it can lead to pelvic inflammatory disease, which causes problems with pregnancy and infertility.
If you think you have gonorrhea it is important to see a doctor as soon as possible. Your doctor can confirm the diagnosis with testing and start treatment. Treatment is with antibiotics. Treating gonorrhea is becoming more difficult because drug-resistant strains are increasing. Correct usage of latex condoms greatly reduces, but does not eliminate, the risk of catching or spreading gonorrhea. The most reliable way to avoid gonorrhea infection is to not have anal, vaginal, or oral sex.
Gonorrhea can be effectively treated with antibiotics. Sometimes you may need to be re-tested after your treatment to make sure the treatment has worked.
It is important to avoid having sex, even with a condom, until treatment is finished and tests show you are cured.
It is also very important to tell all your sexual partners from the past three months that you have been diagnosed with gonorrhea. They will need to be tested for gonorrhea and treated if infected.
Your doctor will help you decide who you need to tell and how you can tell them.
Infection with gonorrhea (Neisseria gonorrhoeae) is a significant public health problem in the United States. A total of 555,608 cases of gonorrhea were reported in the United States in 2017 and this was a significant increase from the 468,514 reported cases in 2016 1). Gonorrhea is the second most commonly reported notifiable disease in the United States. Infections due to gonorrhea (Neisseria gonorrhoeae), like those resulting from Chlamydia trachomatis, are a major cause of pelvic inflammatory disease (PID) in the United States. Pelvic inflammatory disease (PID) can lead to serious outcomes in women, such as tubal infertility, ectopic pregnancy, and chronic pelvic pain. In addition, epidemiologic and biologic studies provide evidence that gonococcal infections facilitate the transmission of HIV infection 2). For 2017, the rate of reported gonorrhea cases among men (202.5 cases per 100,000 males) was significantly higher than among women (141.8 cases per 100,000 females) 3). Over the 1-year period of 2016–2017, the rates of reported gonorrhea increased 19.3% among men and 17.8% among women 4). In 2017, the highest rates of gonorrhea among women were observed among those aged 20-24 years (648.8 cases per 100,000 females) and 15-19 years (557.4 cases per 100,000 females). Among men, the rate was highest among those aged 20-24 years (705.2 cases per 100,000 males) and 25–29 years (645.9 cases per 100,000 males) 5).
Gonorrhea infection in children
Perinatal infections most often occur during childbirth when the neonatal conjunctiva, pharynx, respiratory tract, or anal canal may become infected. Conjunctivitis (ophthalmia neonatorum) is preventable by ocular antimicrobial prophylaxis in the newborn. All cases of gonorrhea beyond the newborn period should be considered possible evidence of sexual abuse. Vulvovaginitis (not cervicitis) is the most common manifestation in prepubescent girls. Signs and symptoms may include vaginal discharge (often purulent or crusting), dysuria, odor, irritation, and pruritus. The anorectum and the pharynx are the most frequently infected sites in abused boys; urethritis is less frequently seen. If specimens are to be collected, proper guidelines for collecting forensic evidence must be followed. When evaluating a child who has potentially suffered sexual abuse, the clinician should consult individual state laws concerning reporting and counseling.
How do you get gonorrhea?
Anyone who is sexually active can get gonorrhea. Gonorrhea is spread by having unprotected vaginal, anal or oral sex with an infected person.
Gonorrhea can also be passed from an infected mother to her baby during birth, which can cause eye infection (neonatal conjunctivitis) and even blindness.
The transmission of gonorrhea can occur in several ways:
- Male-to-female transmission of gonorrhea via semen occurs at a rate of approximately 50% to 70% per episode of vaginal intercourse with ejaculation; male-to-female transmission of gonorrhea can occur without ejaculation 6).
- An infected woman can transmit gonorrhea to the urethra of a male sex partner; the rate of transmission is approximately 20% per episode from vaginal intercourse, and it increases to approximately 60% to 80% after four or more intercourse exposures 7).
- Pharyngeal gonorrhea is readily acquired by fellatio; it is less efficiently acquired by cunnilingus. Gonorrhea can also be transmitted from the pharynx to the urethra during fellatio (and presumably to vagina with cunnilingus).
- Perinatal transmission (mother-to-infant) can occur during vaginal delivery, when the infected mother has not been treated during the perinatal period.
Rectal intercourse transmission rates have not been quantified, but rectal intercourse appears to be an efficient mode of transmission.
- Gonorrhea is associated with increased susceptibility to HIV acquisition. It is also associated with an increase in HIV transmission, because gonococcal urethritis increases HIV shedding in men 8).
Risk factors for getting gonorrhea
Risk factors and risk markers for acquiring gonorrhea include:
- Younger age
- Being adolescent (especially female)
- A new sex partner
- Multiple sex partners
- A sex partner who has concurrent partners
- Inconsistent or incorrect condom use
- Living in an urban area where gonorrhea prevalence is high
- Having a lower socio-economic status
- Using drugs including alcohol (in association with higher risk sex)
- Exchanging sex for drugs or money
- African American race
- Previous gonorrhea diagnosis
- Having other sexually transmitted infections
Is gonorrhea curable?
Yes. Gonorrhea can be cured with the right treatment. The Centers for Disease Control and Prevention (CDC) recommends dual therapy or using two drugs, to treat gonorrhea – a single dose of 250mg of intramuscular ceftriaxone AND 1g of oral azithromycin. It is important to take all of the medication prescribed to cure gonorrhea. Medication for gonorrhea should not be shared with anyone. Although medication will stop the infection, it will not repair any permanent damage done by the disease. Antimicrobial resistance in gonorrhea is of increasing concern, and successful treatment of gonorrhea is becoming more difficult. If a person’s symptoms continue for more than a few days after receiving treatment, he or she should return to a health care provider to be reevaluated.
Practicing safe sex is the best way to prevent gonorrhea infection.
Take steps to reduce your risk of gonorrhea:
- Always use condoms with a water-based lubricant if you choose to have sex. Abstaining from sex is the surest way to prevent gonorrhea. But if you choose to have sex, use a condom during any type of sexual contact, including anal sex, oral sex or vaginal sex.
- Always use dental dams for oral sex (a dental dam is a thin square of latex placed over the vulva or anus during oral sex).
- Limit your sex partners or have a long-term monogamous relationship where neither of you is already infected.
- Ask your partner to be tested for sexually transmitted infections. Find out whether your partner has been tested for sexually transmitted infections, including gonorrhea. If not, ask whether he or she would be willing to be tested.
- Don’t have sex with someone who has any unusual symptoms. If your partner has signs or symptoms of a sexually transmitted infection, such as burning during urination or a genital rash or sore, don’t have sex with that person.
- Avoid sex with someone infected with gonorrhea until after they have finished treatment and are cured.
- Have regular sexually transmitted infection (STI) check-ups. Annual screening is recommended for all sexually active women less than 25 years of age and for older women at increased risk of infection, such as those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection. Regular screening is also recommended for men who have sex with men, as well as their partners.
To avoid reinfection with gonorrhea, abstain from unprotected sex for seven days after you and your sex partner have completed treatment and after resolution of symptoms, if present.
Screening for gonococcal infection
Routine screening for gonorrhea infection in women is recommended in order to decrease morbidity as well as to reduce the burden of disease in the community 9). Urethral infections caused by gonorrhea among men usually produce symptoms that cause them to seek curative treatment soon enough to prevent sequelae, but transmission to others may occur in this interim. Among women, gonococcal infections are commonly asymptomatic until complications (such as pelvic inflammatory disease with resultant risk for infertility and ectopic pregnancy) have occurred. The following summarizes gonorrhea screening recommendations issued by the CDC and the U.S. Preventive Services Task Force (USPSTF) for different patient populations 10), 11):
- Sexually Active Women Who Have Sex with Men: The CDC 12) and the U.S. Preventive Services Task Force 13) recommend (1) annual screening for gonorrhea in all sexually active women younger than 25 years of age, and (2) annual screening for gonorrhea in sexually active women age 25 years and older if they are considered to have increased risk for gonococcal infection. The most important identified risk factors for gonococcal infection include a new sex partner, multiple sex partners, a sex partner with concurrent partners, or a sex partner with a sexually transmitted infection; additional factors that indicate risk of gonococcal infection include inconsistent condom use in persons not in a mutually monogamous relationship, exchange of sex for money or drugs, one or more previous sexually transmitted infections, or a coexistent sexually transmitted infection. Women diagnosed with gonorrhea infection should have repeat testing approximately 3 months after completing treatment.
- Women Who Have Sex with Women: The CDC recommends gonococcal screening for women who have sex with women should occur according to the current screening guidelines for sexually active women who have sex with men 14).
- Women Who are Pregnant: The CDC recommends screening for gonorrhea should be performed at the first prenatal visit for (1) women younger than age 25 and (2) women age 25 years and older who are at increased risk for gonorrhea (e.g. women with a new sex partner, a sex partner who has a sexually transmitted infection, more than one sex partner, or a sex partner with concurrent partners 15). Additional factors associated with increased risk of gonococcal infection include inconsistent condom use in persons not in a mutually monogamous relationship, exchange of sex for money or drugs, and previous or coexisting sexually transmitted infections. A repeat test for gonococcal infection should be performed during the third trimester for those at continued risk. Pregnant women diagnosed with gonorrhea infection should have repeat testing approximately 3 months after completing treatment 16).
- Men Who Have Sex Only with Women: Routine screening for gonococcal infection is not recommended by either the CDC or the USPSTF for men who have sex only with women.[10,27]
- Men Who Have Sex with Men: The CDC 17) recommends screening for gonococcal infection in men who have sex with men at least annually, regardless of a history of condom use during sexual contact; the sites tested should correspond with sites involved in sexual activity with other men during the prior year (e.g. urethral testing if insertive intercourse, rectal testing if receptive anal intercourse, and pharyngeal testing with receptive oral intercourse). The U.S. Preventive Services Task Force 18) does not recommend routine screening for gonorrhea in men, including men who have sex with men.
- Transgender Men and Women: The CDC 19) recommends screening for gonorrhea in transgender men (“trans-men”) and transgender women (“trans-women”) should be based on age, current anatomy, and sexual practices.
- Persons with HIV Infection: The CDC 20) recommends performing routine screening for gonorrhea for persons with HIV infection who are sexually active; testing for gonorrhea should be performed at the initial evaluation and at least annually thereafter (more frequent screening may be indicated based on risk). The testing should consist of obtaining samples from the anatomic sites of sexual exposure.
- Persons in Correctional Facilities: The CDC 21) recommends performing routine gonococcal screening at the initial intake in a correctional facility for women 35 years of age and younger and men younger than age 30.
Gonorrhea signs and symptoms
Most women with gonorrhea have no symptoms at all.
Some men, especially those with throat or anus infection, also have no symptoms.
Occasionally gonorrhea can involve the eyes, joints, heart or brain, causing permanent damage.
Gonorrhea symptoms in men
In men, when symptoms do occur, they usually develop within one to three days. In men, gonorrhea symptoms may include:
- thick, yellow or white discharge from the penis
- pain, discomfort or burning sensation when passing urine
- pain or swelling in one testis (balls)
- redness around the opening of the penis
- anal discharge and discomfort
- sore, dry throat.
Urethritis is a common manifestation of gonorrhea in men. Most men develop overt, symptomatic urethritis, but a small percentage will develop asymptomatic (unrecognized) infection. Asymptomatic gonorrhea may act as a reservoir that perpetuates transmission in the community 22). The typical symptoms of gonococcal urethritis, when present, include a purulent or mucopurulent urethral discharge (Figure 12), often accompanied by dysuria. The discharge may also be clear or cloudy. The incubation period ranges from 1 to 14 days, with most men becoming symptomatic within 2 to 5 days after exposure 23).
Anorectal infection most often occurs in men who have sex with men, with acquisition of rectal gonorrhea occurring through receptive anal intercourse, but it also has been reported in women with gonococcal cervicitis who do not acknowledge rectal sexual contact. These infections may result from perineal contamination with infected cervical secretions. Most patients with anorectal infection are asymptomatic, although proctitis can occur. Symptoms of proctitis include anal irritation, painful defecation, constipation, scant rectal bleeding, painless mucopurulent discharge, anal pruritus, and tenesmus. When proctitis is suspected, an anoscopic examination is recommended to assess for inflammation and mucosal injury. The anorectal mucosa may appear normal, but purulent discharge, erythema, or easily induced bleeding may be observable under anoscopy.
Complications of genital infection in men
Men with untreated gonococcal genital infection can develop epididymitis, with typical symptoms of unilateral testicular pain and swelling, and epididymal tenderness. Epididymitis is infrequent following gonococcal infection, but it is the most common local complication of gonorrhea infection in men. When it does occur, epididymitis is often associated with overt or subclinical urethritis. Urethral discharge may or may not be present. Notably, up to 70% of epididymitis caused by a sexually transmitted pathogen are due to Chlamydia trachomatis. Other less common complications associated with gonococcal infection in men include inguinal lymphadenitis, penile edema, periurethral abscess or fistula, accessory gland infection (Tyson’s glands), balanitis, urethral stricture, and prostatitis, and rarely perirectal abscess.
Gonorrhea symptoms in women
In women, when symptoms do occur, they usually develop within 10 days of infection. In women, gonorrhea symptoms may include:
- unusual vaginal discharge
- pain, discomfort or burning sensation when passing urine
- pelvic pain, especially during sex
- irregular vaginal bleeding, especially between periods or after sex
- abdominal or pelvic pain
- anal discharge and discomfort
- sore, dry throat.
Symptomatic gonococcal infection in women most often manifests as cervicitis and/or urethritis, but at least 50% of women with genital gonococcal infection are asymptomatic. Symptoms of cervicitis vary and may include a nonspecific vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, and dyspareunia. Clinically, examination of the cervix may show mucopurulent or purulent cervical discharge and easily bleed with minimal contact. The incubation period in women is variable, but symptoms, when they do occur, usually develop within 10 days of the exposure. Seventy to ninety percent of women with genital gonococcal infection have laboratory evidence of urethral infection (urethritis); dysuria may be present, but these women frequently do not have specific urethral symptoms.
Anorectal gonococcal infection is uncommon in women, but can occur via anal intercourse. Anorectal infection has been reported in women with gonococcal cervicitis who do not acknowledge rectal sexual contact, presumably these infections result from perineal contamination with infected cervical secretions.
Complications in genital infection in women
There are several complications associated with gonorrhea in women:
- Accessory gland infections: Infection of female sex accessory glands (Bartholin’s glands or Skene’s glands) is often a unilateral infection. Occlusion of the ducts of these glands due to inflammation may result in the formation of an abscess.
- Pelvic inflammatory disease (PID): If cervical gonococcal infection ascends to the endometrium and/or fallopian tubes, PID may develop, typically causing symptoms that include lower abdominal pain, vaginal discharge, dyspareunia, intermenstrual bleeding, and fever. In some women, PID may also be asymptomatic. Presumptive treatment for PID should be considered if one or more of the following minimum criteria are present on pelvic examination—uterine or adnexal tenderness or cervical motion tenderness. The long-term sequelae of untreated PID can include chronic pelvic pain, tubal infertility, and increased risk for ectopic pregnancy.
- Perihepatitis (Fitz-Hugh-Curtis Syndrome): In situations where gonococcal infection ascends from the cervix, infection may produce inflammation of the liver capsule and the adjacent peritoneum. Most women with perihepatitis have associated PID, but perihepatitis can occur independently. Historically, perihepatitis was attributed only to gonococcal infection, but now it is often associated with chlamydial infection. Gonococcal perihepatitis is characterized by right upper quadrant pain, and may be accompanied by abnormal liver function tests.
Signs of gonorrhea
Gonorrhea can also affect these parts of the body:
- Rectum. Signs and symptoms include anal itching, pus-like discharge from the rectum, spots of bright red blood on toilet tissue and having to strain during bowel movements.
- Eyes. Gonorrhea that affects your eyes may cause eye pain, sensitivity to light, and pus-like discharge from one or both eyes.
- Throat. Signs and symptoms of a throat infection may include a sore throat and swollen lymph nodes in the neck.
- Joints. If one or more joints become infected by bacteria (septic arthritis), the affected joints may be warm, red, swollen and extremely painful, especially when you move an affected joint.
Gonococcal pharyngeal infection is most often asymptomatic. The pharynx may be the sole site of infection if the only exposure was receptive orogenital intercourse. Exudative pharyngitis is rare. Symptoms of pharyngeal infection may include pharyngitis, tonsillitis, fever, and cervical adenitis.
Gonococcal infection of the eye, when it does occur, typically presents as conjunctivitis. Gonococcal conjunctivitis in adults most often results from autoinoculation in persons with genital gonococcal infection. Patients may initially develop a mild non-purulent conjunctivitis, that, if untreated, typically progress to marked conjunctival redness, copious purulent discharge, and conjunctival edema 24). Less often, the manifestations include an ulcerative keratitis. Untreated gonococcal conjunctivitis can cause complications that may include corneal perforation, endophthalmitis, and blindness.
Disseminated Gonococcal Infection
Disseminated gonococcal infection, a systemic gonococcal infection, occurs infrequently and is more common in women than in men. Disseminated gonococcal infection is associated with some gonococcal strains that have a propensity to produce bacteremia without associated urogenital symptoms. In addition, patients with complement deficiency have greater risk of developing disseminated gonococcal infection. Clinical manifestations of disseminated gonococcal infection include skin lesions, arthralgia, tenosynovitis, arthritis, hepatitis, myocarditis, endocarditis, and meningitis. Rates of disseminated gonococcal infection have decreased due to the declining proportion of gonococcal strains prone to disseminate 25).
Untreated gonorrhea can lead to significant complications, such as:
- Infertility in women. Untreated gonorrhea can spread into the uterus and fallopian tubes, causing pelvic inflammatory disease (PID), which may result in scarring of the tubes, greater risk of pregnancy complications and infertility. PID is a serious infection that requires immediate treatment.
- Infertility in men. Men with untreated gonorrhea can experience epididymitis — inflammation of a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis). Epididymitis is treatable, but if left untreated, it may lead to infertility.
- Infection that spreads to the joints and other areas of your body. The bacterium that causes gonorrhea can spread through the bloodstream and infect other parts of your body, including your joints. Fever, rash, skin sores, joint pain, swelling and stiffness are possible results.
- Increased risk of HIV/AIDS. Having gonorrhea makes you more susceptible to infection with human immunodeficiency virus (HIV), the virus that leads to AIDS. People who have both gonorrhea and HIV are able to pass both diseases more readily to their partners.
- Complications in babies. Babies who contract gonorrhea from their mothers during birth can develop blindness, sores on the scalp and infections.
Testing for gonorrhea involves taking a swab (sample) from the urethra in men and the cervix in women. It can also be tested by taking a urine sample.
Sometimes swabs are also be taken from the throat and anus.
It is also important to get tested for other sexually transmitted infections such as syphilis, chlamydia and HIV.
To determine whether the gonorrhea bacterium is present in your body, your doctor will analyze a sample of cells. Samples can be collected by:
- Urine test. This may help identify bacteria in your urethra.
- Swab of affected area. A swab of your throat, urethra, vagina or rectum may collect bacteria that can be identified in a laboratory.
For women, home test kits are available for gonorrhea. Home test kits include vaginal swabs for self-testing that are sent to a specified lab for testing. If you prefer, you can choose to be notified by email or text message when your results are ready. You may then view your results online or receive them by calling a toll-free hotline.
Testing for other sexually transmitted infections
Your doctor may recommend tests for other sexually transmitted infections. Gonorrhea increases your risk of these infections, particularly chlamydia, which often accompanies gonorrhea. Testing for HIV also is recommended for anyone diagnosed with a sexually transmitted infection. Depending on your risk factors, tests for additional sexually transmitted infections could be beneficial as well.
The approach to diagnostic testing for gonorrhea has evolved from traditional cultivation to widespread use of nucleic acid amplification tests (NAAT) 26). Gram’s stain, another non-culture test, is used for the diagnosis of urethral gonorrhea in symptomatic males. Culture is still recommended if antimicrobial resistance is a concern, especially in cases of treatment failure.
Nucleic Acid Detection Tests
There are two types of nucleic acid detection tests: non-amplified tests and amplified tests:
- Amplified Tests: The nucleic acid amplification tests (NAATs) include polymerase chain reaction (PCR) (Roche Amplicor; Cepheid GeneXpert CT/NG), transcription-mediated amplification (TMA) (Gen-Probe Aptima), and strand displacement amplification (SDA) (Becton-Dickinson BDProbeTec ET) 27). Amplified tests are FDA-cleared for endocervical specimens from women, urethral specimens from men, and urine specimens from men and women. Some NAATs are also cleared for vaginal swabs. For many of the commercially available tests, the same specimen can be used to test for Chlamydia trachomatis infection. NAATs are the most sensitive test to detect gonorrhea infections. NAATs are not FDA-cleared for rectal or oropharyngeal specimens, though many individual laboratories have validated NAAT for non-genital sites and this practice is becoming increasingly common 28). At present, antimicrobial susceptibility cannot be determined with NAATs, but research in this area is ongoing.
- Non-Amplified Tests: Non-amplified tests used for gonorrhea include the DNA probe (e.g. Gen-Probe PACE 2 and Digene Hybrid Capture II). A non-amplified test is less likely to be affected by transport conditions than culture, and has the potential for more timely results. These tests are FDA-cleared for endocervical specimens from women and urethral specimens from men. They are not FDA-cleared for pharyngeal, rectal, or urine specimens. The same specimen can be evaluated for Chlamydia trachomatis infection 29). Antimicrobial susceptibility cannot currently be determined with non-amplified tests.
The use of Gram’s stain is a non-culture test that can make a presumptive diagnosis of gonorrhea. In the clinical setting, a Gram’s stain to detect gonorrhea is most often performed on a male with purulent urethral discharge. A Gram’s stain on a specimen positive for gonorrhea shows polymorphonuclear leukocytes (PMNs) with intracellular gram-negative diplococci. A Gram’s stain, with proper laboratory technique, has greater than 95% sensitivity and greater than 99% specificity for diagnosing symptomatic male gonococcal urethritis 30). Thus, the Gram’s stain is considered reliable both to diagnose and to exclude gonococcal urethritis in symptomatic men 31). The sensitivity of a Gram’s stain is lower for mane with asymptomatic urethral infection and thus not considered adequate to rule out infection in asymptomatic men 32). Performing a Gram’s stain is not recommended on endocervical, pharyngeal, or rectal specimens due to poor sensitivity 33).
Obtaining a bacterial culture is the historic standard for detection of gonorrhea. It has several advantages over non-culture tests, including low cost, use for a variety of specimen sites, and antimicrobial susceptibility testing can be performed if gonorrhea is isolated from the specimen. Despite having some advantages, culture is not as sensitive as NAAT and is more laboratory intensive, which has led to infrequent use in modern practice. At present, culture is primarily used for antimicrobial resistance surveillance by collecting specimens from either symptomatic urethral infections or from screen-positive sites of infection prior to treatment.
Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the Centers for Disease Control and Prevention (CDC) recommends that uncomplicated gonorrhea be treated only with the antibiotic ceftriaxone — given as an injection — in combination with either azithromycin (Zithromax, Zmax) or doxycycline (Monodox, Vibramycin, others) — two antibiotics that are taken orally.
Some research indicates that oral gemifloxacin (Factive) or injectable gentamicin, combined with oral azithromycin, is highly successful in treating gonorrhea. This treatment may be helpful in treating people who are allergic to cephalosporin antibiotics, such as ceftriaxone.
Gonorrhea treatment for partners
Your partner also should undergo testing and treatment for gonorrhea, even if he or she has no signs or symptoms. Your partner receives the same treatment you do. Even if you’ve been treated for gonorrhea, you can be reinfected if your partner isn’t treated.
Gonorrhea treatment for babies
Babies born to mothers with gonorrhea receive a medication in their eyes soon after birth to prevent infection. If an eye infection develops, babies can be treated with antibiotics.
Antibiotics for gonorrhea
The CDC treatment guidelines recommend using dual therapy for the treatment of gonococcal infections in adults and adolescents. Ceftriaxone is the most effective cephalosporin for treatment of gonorrhea and should be used in combination with azithromycin. The recommendation for dual therapy is based on the premise that using two antimicrobials with different mechanisms of action (e.g. a cephalosporin plus azithromycin) may improve treatment efficacy and potentially slow the emergence and spread of resistance. In addition, azithromycin and doxycycline will effectively treat concomitant C. trachomatis infection, if present. Azithromycin is preferred over doxycycline as a second agent due to convenience (single-dose therapy versus 7-day therapy) and the substantially lower prevalence of gonococcal resistance to azithromycin than with doxycycline, particularly for gonococcal strains that have an elevated cefixime MIC. In the case of azithromycin allergy or severe intolerance, doxycycline (100 mg orally twice a day for 7 days) can be used as a substitute for azithromycin, but doxycycline should only be used as an alternative, primarily because of the high prevalence of gonococcal tetracycline resistance. For details regarding these alternative regimens, refer to the section on gonococcal infections in the 2015 STD Treatment Guidelines 34). The following recommendations for treatment are based on the 2015 STD Treatment Guidelines.
Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum
- Ceftriaxone 250 mg IM in a single dose
- Azithromycin 1g orally in a single dose
As dual therapy, ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously and under direct observation. Ceftriaxone in a single injection of 250 mg provides sustained, high bactericidal levels in the blood. Extensive clinical experience indicates that ceftriaxone is safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of uncomplicated urogenital and anorectal and 98.9% of pharyngeal infections in clinical trials 35). No clinical data exist to support use of doses of ceftriaxone >250 mg.
Single-dose injectable cephalosporin regimens (other than ceftriaxone 250 mg IM) that are safe and generally effective against uncomplicated urogenital and anorectal gonococcal infections include ceftizoxime (500 mg IM), cefoxitin (2 g IM with probenecid 1 g orally), and cefotaxime (500 mg IM). None of these injectable cephalosporins offer any advantage over ceftriaxone for urogenital infection, and efficacy for pharyngeal infection is less certain 36).. Several other antimicrobials are active against gonorrhea, but none have substantial advantages over the recommended regimen, and efficacy data (especially for pharyngeal infection) are limited.
If ceftriaxone is not available:
- Cefixime 400 mg orally in a single dose
- Azithromycin 1 g orally in a single dose
A 400-mg oral dose of cefixime should only be considered as an alternative cephalosporin regimen because it does not provide as high, nor as sustained, bactericidal blood levels as a 250-mg dose of ceftriaxone; further, it demonstrates limited efficacy for treatment of pharyngeal gonorrhea (92.3% cure); in older clinical studies, cefixime cured 97.5% of uncomplicated urogenital and anorectal gonococcal infections (95%) 37). The increase in the prevalence of isolates obtained through GISP with elevated cefixime MICs might indicate early stages of development of clinically significant gonococcal resistance to cephalosporins. CDC anticipates that rising cefixime MICs soon will result in declining effectiveness of cefixime for the treatment of urogenital gonorrhea. Furthermore, as cefixime becomes less effective, continued used of cefixime might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial known to be highly effective in a single dose for treatment of gonorrhea at all anatomic sites of infection. Other oral cephalosporins (e.g., cefpodoxime and cefuroxime) are not recommended because of inferior efficacy and less favorable pharmacodynamics 38).
Uncomplicated Gonococcal Infections of the Pharynx
Most gonococcal infections of the pharynx are asymptomatic and can be relatively common in some populations 39). Gonococcal infections of the pharynx are more difficult to eradicate than are infections at urogenital and anorectal sites 40). Few antimicrobial regimens, including those involving oral cephalosporins, can reliably cure >90% of gonococcal pharyngeal infections 41). Providers should ask their patients with urogenital or rectal gonorrhea about oral sexual exposure; if reported, patients should be treated with a regimen with acceptable efficacy against pharyngeal gonorrhea infection.
- Ceftriaxone 250 mg IM in a single dose
- Azithromycin 1 g orally in a single dose
In the only published study of the treatment of gonococcal conjunctivitis among adults, all 12 study participants responded to a single 1 g intramuscular injection of ceftriaxone 42). Nevertheless, due to concerns for emergence of antimicrobial resistance with gonorrhea, the CDC’s recommendation is to treat with ceftriaxone 1 g intramuscular injection once and azithromycin 1 g orally as a single dose. In addition, a one-time lavage of the infected eye with saline should be considered.
- Ceftriaxone 1 g IM in a single dose
- Azithromycin 1 g orally in a single dose
Disseminated Gonococcal Infection
Disseminated gonococcal infection frequently results in petechial or pustular acral skin lesions, asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. Because of the possibility of potentially severe sequelae associated with these complications, the 2015 STD Treatment Guidelines recommend hospitalization and consultation with an infectious diseases specialist for patients suspected of having disseminated gonococcal infection. The recommended initial therapy is ceftriaxone 1 g intramuscularly or intravenously every 24 hours plus azithromycin 1 g orally in a single dose. The first dose is given ideally after promptly obtaining cultures and NAATs from multiple sites, as indicated, including skin, synovial fluid, blood, and cerebrospinal fluid. The duration of therapy for disseminated gonococcal infection with arthritis-dermatitis syndrome is at least 7 days and the ceftriaxone can transition to oral therapy if antimicrobial sensitivity testing shows an effective oral choice 43). For patients with meningitis, parenteral therapy should continue for 10 to 14 days and with endocarditis parenteral therapy should be given for at least 4 weeks 44).
Treatment of Arthritis and Arthritis-Dermatitis Syndrome
- Ceftriaxone 1 g IM or IV every 24 hours
- Azithromycin 1 g orally in a single dose
- Cefotaxime 1 g IV every 8 hours
- Ceftizoxime 1 g IV every 8 hours
- Azithromycin 1 g orally in a single dose
When treating for the arthritis-dermatitis syndrome, the provider can switch to an oral agent guided by antimicrobial susceptibility testing 24–48 hours after substantial clinical improvement, for a total treatment course of at least 7 days.
Treatment of Gonococcal Meningitis and Endocarditis
- Ceftriaxone 1–2 g IV every 12–24 hours
- Azithromycin 1 g orally in a single dose
No recent studies have been published on the treatment of disseminated gonococcal infection. The duration of treatment of disseminated gonococcal infection has not been systematically studied and should be determined in consultation with an infectious-disease specialist. Treatment for disseminated gonococcal infection should be guided by the results of antimicrobial susceptibility testing. Pending antimicrobial susceptibility results, treatment decisions should be made on the basis of clinical presentation. Therapy for meningitis should be continued with recommended parenteral therapy for 10–14 days. Parenteral antimicrobial therapy for endocarditis should be administered for at least 4 weeks.
Gonococcal Infections in Pregnancy
As with other patients, pregnant women infected with gonorrhea should be treated with recommended cephalosporin-based therapy in combination with azithromycin. Pregnant women infected with gonorrhea should be treated with dual therapy consisting of ceftriaxone 250 mg in a single IM dose and azithromycin 1 g orally as a single dose. Pregnant women should not be treated with any fluoroquinolone or any tetracycline drug. Because spectinomycin is not available in the United States, pregnant women who cannot tolerate a cephalosporin should be evaluated by an infectious diseases specialist.
Management of Antibiotic-Resistant Gonorrhea
Although there are no confirmed cases of treatment failure due to cephalosporin-resistant gonorrhea in the United States, the gradual upwards trend of MICs documented by the United States Gonococcal Isolate Surveillance Project remains worrisome 45). Criteria for resistance to cefixime and ceftriaxone have not been defined by the Clinical and Laboratory Standards Institute, but isolates with cefixime or ceftriaxone MICs equal to or greater than 0.5 μg/mL are considered to have decreased susceptibility. Only five isolates with ceftriaxone MIC equal to or greater than 0.5 μg/mL have been reported during the history of the United States Gonococcal Isolate Surveillance Project. Notably, isolates with high-level cefixime and ceftriaxone MICs (cefixime MICs 1.5–8 μg/mL and ceftriaxone MICs 1.5–4 μg/mL) have been identified in Japan, France, and Spain 46).
Allergy to Penicillins or Cephalosporin
Allergic reactions to first-generation cephalosporins occur in less than 2.5% of persons with a history of penicillin allergy and are less common with third-generation cephalosporins such as ceftriaxone and cefixime 47). Ceftriaxone is contraindicated in patients with a history of IgE-mediated anaphylaxis to penicillin. Given these considerations, expert consultation with an infectious diseases specialist (and possibly also an allergy specialist), is recommended for treating gonorrhea among persons who have documented severe cephalosporin allergy. Cephalosporin desensitization is preferred but impractical in many settings. Potential therapeutic options in this situation for adults and adolescents include (1) dual treatment with single doses of oral gemifloxacin 320 mg plus a single dose of oral azithromycin 2 g, or (2) dual treatment with single doses of intramuscular gentamicin 240 mg plus a single dose of oral azithromycin 2 g 48). Note that since May 2015, gemifloxacin has not available for use in the United States because of a legal dispute regarding the license to manufacture and distribute this drug. For patients with documented severe cephalosporin allergy, recent evidence supports superior effectiveness of dual therapy when compared with azithromycin monotherapy. In this setting, spectinomycin monotherapy has been effective in clinical trials, curing 98.2% of uncomplicated urogenital and anorectal gonococcal infections, but it has poor efficacy against pharyngeal infection and is not currently available in the United States. Although true allergic reactions to third-generation cephalosporins are uncommon among persons who report a history of penicillin allergy, use of ceftriaxone is contraindicated in persons with a history of IgE-mediated penicillin allergy.
Management of Suspected Gonococcal Treatment Failure
Clinicians who diagnose gonorrhea infection in a person with suspected cephalosporin treatment failure should (1) perform culture and susceptibility testing of all relevant clinical specimens; (2) obtain expert opinion for guidance in clinical management (through the STD Clinical Consultation Network [https://stdccn.org], a local STD/HIV Prevention Training Center clinical expert, the CDC, or an infectious diseases specialist); and (3) report the case to the CDC through state and local public health authorities 49). Isolates that grow gonorrhea should be saved and sent to the CDC through state public health laboratory mechanisms. Health departments should prioritize notification and culture evaluation for sex partner(s) of persons with gonorrhea infection suspected for cephalosporin treatment failure or persons whose isolates demonstrate decreased susceptibility to cephalosporins. In this setting, a test-of-cure at relevant clinical sites should be obtained 7 to 14 days after retreatment; culture is the recommended test, preferably with simultaneous NAAT and susceptibility testing of gonorrhea if isolated. For patients considered to have high likelihood of true treatment failure, especially those with a documented elevated cephalosporin MIC for gonorrhea, the 2015 STD Treatment Guidelines suggested options consist of (1) single dose oral therapy with gemifloxacin 320 mg plus azithromycin 2 g, or (2) single dose oral therapy with azithromycin 2 g plus a single intramuscular injection of a 240 mg dose of gentamicin. Note that since May 2015, gemifloxacin has not available for use in the United States because of a legal dispute regarding the license to manufacture and distribute this drug.
In general, a test-of-cure is not recommended for patients who have uncomplicated gonorrhea and are treated with any of the recommended regimens. Patients who have persistent symptoms should be evaluated by culture for gonorrhea, and any gonococci isolated should be tested for antimicrobial susceptibility. A routine test-of-cure at day 14 after treatment with NAAT or culture is recommended for patients with pharyngeal gonorrhea treated with an alternative regimen. All patients diagnosed with gonorrhea should have repeat testing in 3 months at the anatomic site of exposure, regardless of whether they have symptoms. Infections identified after treatment with one of the recommended regimens usually result from reinfection rather than treatment failure, indicating a need for improved patient education and referral of sex partners. Patients who have persistent infection despite treatment with a recommended regimen and who deny sexual exposure after treatment should be evaluated with culture of clinical specimens and susceptibility testing. Clinicians should promptly notify the local STD program of such cases, and local or state STD programs should notify the CDC.
Management of Sex Partners
Recent sex partners (within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment. The most recent sex partner should be treated regardless of interval from diagnosis. To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sex partner(s) have completed antimicrobial treatment and symptoms have resolved.
Expedited partner therapy
In settings where prompt referral and treatment are unavailable or impractical, providers should consider expedited partner therapy 50). This entails provision of appropriate antibiotics as well as educational and pharmacy information for the partner. The documentation should include notification that partner(s) have been exposed, information about the importance of treatment, signs and symptoms of potential complications, as well as possible therapy-related potential allergic reactions and adverse effects 51). The expedited partner therapy regimen for sex partners of patients with gonorrhea infection is cefixime 400 mg and azithromycin 1 g, with delivery of the prescription to the partner by either the patient, a disease investigation specialist, or a collaborating pharmacy as permitted by law 52). It is essential to check with one’s state health department to clarify the policies, as the use of expedited partner therapy is not legal in all states. The CDC maintains an updated information page Legal Status of Expedited Partner Therapy that identifies the legal status of expedited partner therapy in each state in the United States, as well as providing links to each state for more detailed state policies. Notably, provision of expedited partner therapy alone is not sufficient and each partner should ideally be seen in follow-up for repeat testing to confirm resolution of infection and check for reinfection. Although offering expedited partner therapy to female partners is acceptable, this approach may result in undertreatment of pelvic inflammatory disease. The use of expedited partner therapy for gonorrhea is contraindicated in a female partner who have current signs or symptoms that are suggestive of PID. Female partners who have current signs and symptoms suggestive of PID should undergo prompt evaluation by a health care provider. In addition, the use of expedited partner therapy should not be considered a routine partner management strategy in men who have sex with men with gonorrhea for several reasons, including the high risk for coexisting infections (especially HIV and syphilis infection), inadequate data regarding the efficacy of expedited partner therapy in this patient population, and concerns regarding the increased proportion of gonococcal isolates among men who have sex with men with reduced susceptibility to cefixime.
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