Gonorrhea

What is Gonorrhea

Gonorrhea is a sexually transmitted disease (STD) that can affect both men and women. If left untreated, this infection can:

• Damage the female or male organs.
• Cause women and men to be unable to have children (be sterile).
• Harm a fetus if an infected woman is pregnant.

It is important to get treatment for gonorrhea as soon as possible. It is also necessary for all of your sexual partners to be tested for the infection.

What are the causes?

This condition is caused by bacteria called Neisseria gonorrhoeae. The infection is spread from person to person through sexual contact, including oral, anal, and vaginal sex. A newborn can contract the infection from his or her mother during birth.

What increases the risk?

The following factors may make you more likely to develop this condition:

• Being a woman who is younger than 25 years of age and who is sexually active.
• Being a woman 25 years of age or older who has:
  • A new sex partner.
  • More than one sex partner.
  • A sex partner who has an STD.
• Being a man who has:
  • A new sex partner.
  • More than one sex partner.
  • A sex partner who has an STD.
• Using condoms inconsistently.
• Currently having, or having previously had, an STD.
• Exchanging sex for money or drugs.

What are the symptoms?

Some people do not have any symptoms. If you do have symptoms, they may be different for females and males.

For females

• Pain in the lower abdomen.
• Abnormal vaginal discharge. The discharge may be cloudy, thick, or yellow-green in color.
• Bleeding between periods.
• Painful sex.
• Burning or itching in and around the vagina.
• Pain or burning when urinating.
• Irritation, pain, bleeding, or discharge from the rectum. This may occur if the infection was spread by anal sex.
• Sore throat or swollen lymph nodes in the neck. This may occur if the infection was spread by oral sex.

For males

• Abnormal discharge from the penis. This discharge may be cloudy, thick, or yellow-green in color.
• Pain or burning during urination.
• Pain or swelling in the testicles.
• Irritation, pain, bleeding, or discharge from the rectum. This may occur if the infection was spread by anal sex.
• Sore throat, fever, or swollen lymph nodes in the neck. This may occur if the infection was spread by oral sex.

How is this diagnosed?

This condition is diagnosed based on:

• A physical exam.
• A sample of discharge that is examined under a microscope to look for the bacteria. The discharge may be taken from the urethra, cervix, throat, or rectum.
• Urine tests.

Not all of test results will be available during your visit.

How is this treated?

This condition is treated with antibiotic medicines. It is important for treatment to begin as soon as possible. Early treatment may prevent some problems from developing. Do nothave sex during treatment. Avoid all types of sexual activity for 7 days after treatment is complete and until any sex partners have been treated.

Follow these instructions at home:

• Take over-the-counter and prescription medicines only as told by your health care provider.
• Take your antibiotic medicine as told by your health care provider. Do notstop taking the antibiotic even if you start to feel better.
• Do nothave sex until at least 7 days after you and your partner(s) have finished treatment and your health care provider says it is okay.
• It is your responsibility to get your test results. Ask your health care provider, or the department performing the test, when your results will be ready.
• If you test positive for gonorrhea, inform your recent sexual partners. This includes any oral, anal, or vaginal sex partners. They need to be checked for gonorrhea even if they do not have symptoms. They may need treatment, even if they test negative for gonorrhea.
• Keep all follow-up visits as told by your health care provider. This is important.

How is this prevented?

• Use latex condoms correctly every time you have sexual intercourse.
• Ask if your sexual partner has been tested for STDs and had negative results.

Avoid having multiple sexual partners.

Contact a health care provider if:

• You develop a bad reaction to the medicine you were prescribed. This may include:
  • A rash.
  • Nausea.
  • Vomiting.
  • Diarrhea.
• Your symptoms do not get better after a few days of taking antibiotics.
• Your symptoms get worse.
• You develop new symptoms.
• Your pain gets worse.
• You have a fever.
• You develop pain, itching, or discharge around the eyes.

Get help right away if:

• You feel dizzy or faint.
• You have trouble breathing or have shortness of breath.
• You develop an irregular heartbeat.
• You have severe abdominal pain with or without shoulder pain.
• You develop any bumps or sores (lesions)on your skin.
• You develop warmth, redness, pain, or swelling around your joints, such as the knee.

Summary

• Gonorrhea is an STD that can affect both men and women.
• This condition is caused by bacteria called Neisseria gonorrhoeae. The infection is spread from person to person, usually through sexual contact, including oral, anal, and vaginal sex.
• Symptoms vary between males and females. Generally, they include abnormal discharge and burning during urination. Women may also experience painful sex, itching around the vagina, and bleeding between menstrual periods. Men may also experience swelling of the testicles.
• This condition is treated with antibiotic medicines. Do not have sex until at least 7 days after completing antibiotic treatment.
• If left untreated, gonorrhea can have serious side effects and complications.

Detailed Info on Gonorrhea

8 Interesting Facts of Gonorrhea

1. Gonorrhea, caused by Neisseria gonorrhoeae, is the second most common sexually transmitted infection in the United States; the highest incidence is in young adults and men who have sex with men
2. Reportable disease in every state and a nationally notifiable disease in the United States
3. Infection may be asymptomatic, especially in females and at nongenital sites such as the pharynx and rectum
4. Screen young, sexually active females, men who have sex with men, and others at high risk for gonorrhea (and chlamydia) annually
5. Symptomatic infection usually presents:
   • In males as urethritis
   • In females as urethritis, vaginitis, and/or cervicitis, or an ascending infection of the pelvic organs
6. Use nucleic acid amplification testing of urine or swab of infected area for both screening and diagnosis
7. CDC recommends treating uncomplicated urogenital, anorectal, and pharyngeal gonorrhea with a single dose of ceftriaxone 
8. If symptoms persist after treatment, retest and include culture with antibiotic sensitivities

Pitfalls

• Antibiotic resistance in Neisseria gonorrhoeae continues to evolve and should be considered in cases of treatment failure
• Treatment failure requires culture and susceptibility testing for persistent gonorrhea (as well as evaluation for alternative explanations)

• Gonorrhea, caused by Neisseria gonorrhoeae, is the second most common sexually transmitted infection in the United States; the highest incidence is in young adults and men who have sex with men
• Reportable disease in every state and a nationally notifiable disease in the United States

Classification

• Uncomplicated 
  • Causes urethritis, cervicitis, pharyngitis, and proctitis
• Complicated
  • Extends beyond the primary site of infection (eg, epididymitis, pelvic inflammatory disease, disseminated infection)

Clinical Presentation

History

• Take a detailed sexual history
  • Inquire about recent travel (and sexual contact) outside the United States, as antimicrobial resistance in these patients is more common 
• In females, acute gonorrhea infection presents as follows:
  • Asymptomatic (common; up to 95% of cases)
  • Urethritis, vaginitis, and/or cervicitis, with dysuria, dyspareunia, and/or purulent vaginal discharge
  • Salpingitis, endometritis, and/or more diffuse pelvic infection with possible abdominal pain, pelvic pain, dyspareunia, hypermenorrhea, and/or fever
    • Pelvic inflammatory disease caused by gonorrhea with or without copathogens may present with these symptoms as well as those of cervicitis
  • Light intermenstrual bleeding and postcoital spotting if there is a lower genitourinary tract or pelvic infection
  • Proctitis with painful bowel movements and purulent rectal discharge
  • Pharyngitis, which may be asymptomatic or may cause sore throat
  • Right upper quadrant pain may reflect the presence of perihepatitis (Fitz-Hugh–Curtis syndrome)
• In males, acute gonorrhea infection presents as follows:
  • Asymptomatic (estimated 10% of urogenital cases; more common at nongenital sites such as pharynx or rectum)
  • Urethritis with frequency, urgency, dysuria, and purulent, yellow-green discharge
  • Epididymitis with unilateral scrotal pain
  • Prostatitis with frequency, dysuria, and lower abdominal discomfort
  • Proctitis with painful bowel movements and purulent discharge
  • Pharyngitis, which may cause sore throat
• Preadolescent girls usually complain of (or are noticed to have) vaginal discomfort and/or discharge
• Disseminated disease due to bacteremic spread may include any of the following:
  • Arthritis, which presents as:
    • Fever with migratory polyarthralgias, usually of knees and/or elbows, with joint pain and stiffness
    • Monoarticular septic arthritis with fever, pain, swelling, and redness
  • Tenosynovitis, which presents with discomfort and swelling over flexor tendon sheaths, most commonly of wrists and ankles
  • Rash, often involving palms and soles, sometimes described as painful
• Symptoms of genital, rectal, or pharyngeal infection may be present concurrently

Physical examination

• In all patients, any of the following signs may be present:
  • Erythematous pharynx with exudate, swollen tonsils, and/or cervical lymphadenopathy
  • Rectal discharge if proctitis is present
  • Joint involvement, which presents as warm, red, swollen joints, usually asymmetrical
  • Maculopapular to pustular rash, most commonly peripheral, that involves palms and soles; may appear hemorrhagic
• In females, any of the following signs may be present:
  • Fever, especially if ascending pelvic infection is present
    • Absence of fever does not rule out pelvic inflammatory disease
  • Tenderness to palpation
    • Right upper quadrant in perihepatitis (Fitz-Hugh–Curtis syndrome)
    • Lower abdomen: unilateral or bilateral
    • Adnexa and uterus
  • Swollen urethral meatus, Skene ducts, and Bartholin glands, with purulent discharge
  • Erythematous and friable cervix seen during speculum examination; possible mucopurulent cervical discharge
  • Cervical motion tenderness, which is highly suggestive of pelvic inflammatory disease
• In males, any of the following signs may be present:
  • Fever
  • Urethral meatus erythema
  • Purulent urethral discharge; compression may be required to express it
  • Prostate tender to palpation

Causes

• Neisseria gonorrhoeae

Risk factors and/or associations

Age

• Greatest incidence in the United States occurs in people aged 15 to 24 years 

Sex

• From 2013 through 2018, greater incidence in males than in females in the United States 

Ethnicity/race

• Higher incidence in Black populations compared with White populations 
• Higher incidence in Hispanic than non-Hispanic White populations 

Other risk factors/associations

• New sex partner
• Multiple sex partners
• Men who have sex with men
  • Gonorrhea prevalence rate of 16.4% in 2012 
  • In asymptomatic men who have sex with men, 90% of gonococcal infections are at nongenital sites 
• Inconsistent use of condoms
• History of previous sexually transmitted infections

Diagnostic Procedures

Primary diagnostic tools

• History and physical examination 
• Laboratory testing to confirm presence of Neisseria gonorrhoeae and to identify any sexually transmitted coinfection 
  • Infection may be present in multiple sites; have a low threshold to test for pharyngeal and rectal infection as well as urogenital disease
  • In patients with suspected disseminated gonococcal infection, include blood cultures and, if applicable, synovial fluid analysis and culture, in addition to testing possible sites of primary infection
• In females of childbearing age who have pelvic pain, test for pregnancy 
• Imaging is not routinely indicated but may be helpful in females whose symptoms include pelvic pain or in those whose defervescence is slow, suggesting pelvic inflammatory disease or tubo-ovarian abscess 

• Imaging is not routinely indicated but may be helpful in females whose symptoms include pelvic pain or in those whose defervescence is slow, suggesting pelvic inflammatory disease or tubo-ovarian abscess 

Laboratory

• Diagnostic tests for Neisseria gonorrhoeae
  • Nucleic acid amplification test 
    • Is sensitive, specific, and the most convenient test in most settings
    • Can be performed on swabs of urethra (male only), urine, vagina, and endocervix
    • Not FDA-approved for rectal and pharyngeal swabs, but some laboratories have met regulatory requirements set by Clinical Laboratory Improvement Amendments and have established performance specifications for using this test with these specimens
  • Microscopy
    • Symptomatic males: Gram-stained smear of urethral discharge showing gram-negative intracellular diplococci is an acceptable alternative diagnostic test
    • In other presentations (eg, cervicitis, pharyngitis, proctitis), microscopy is significantly less sensitive and specific and cannot be considered diagnostic
  • Culture
    • Thayer-Martin agar or other selective medium; best yield if plates are inoculated immediately by examiner 
      • Diagnostic when positive on the following swabs: urethral (not recommended in females), endocervical, rectal, oropharyngeal, and conjunctival
      • Less sensitive than nucleic acid amplification test
    • With antimicrobial susceptibility testing plus nucleic acid amplification test 
      • Recommended if pelvic inflammatory disease is suspected
  • If patient has persistent symptoms after treatment, perform both culture and antimicrobial susceptibility testing to verify treatment failure and ascertain potentially effective treatment options 
• Test of cure
  • Uncomplicated urogenital or rectal gonorrhea infection treated with recommended (including alternative) antibiotic regimen: test of cure is not performed routinely 
  • Pharyngeal gonorrhea treated with an alternative regimen: test of cure is recommended 14 days after treatment 
    • Either culture or nucleic acid amplification test is acceptable
    • If nucleic acid amplification test result is positive, obtain a confirmatory culture before retreatment
    • All positive culture results for test of cure should undergo antimicrobial susceptibility testing
  • Use routine test of cure for all pregnant patients within 3 months after treatment and again in third trimester 
  • Use test of cure 7 to 14 days after retreatment in all patients whose infection fails to respond to an initial course of therapy 
• Rescreen all patients for Neisseria gonorrhoeae 3 months after treatment, as reinfection is common 
• In addition to testing for Neisseria gonorrhoeae, test patients who are seeking evaluation or treatment of a sexually transmitted infection with the following:
  • All patients 
    • HIV test
    • Nucleic acid amplification test for Chlamydia trachomatis
    • Serologic test for syphilis
  • Patients with cervicitis 
    • Bacterial vaginosis test
    • Trichomoniasis test
  • Patients with proctitis or males with anogenital symptoms
    • HSV test

Imaging

• Women of childbearing age who present with acute pelvic pain: transvaginal and transabdominal ultrasonography are recommended 
  • Findings in pelvic inflammatory disease may include thickening of fallopian tubes, adnexal or para-ovarian mass, or tubo-ovarian abscess
  • Absence of abnormal findings does not exclude diagnosis of pelvic inflammatory disease

Differential Diagnosis

Most common

• Nongonococcal urethritis and/or cervicitis
  • Caused by Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, and Trichomonas vaginalis
    • Trichomonas vaginalis results in a malodorous yellow-green frothy vaginal discharge
    • Mycoplasma genitalium and Ureaplasma urealyticum are not routinely tested for in most clinical laboratories
      • Suspect if symptoms persist after antibiotic treatment of urethritis or cervicitis
  • Symptoms are similar to those of gonococcal urethritis or cervicitis
  • In young males, assume that urethral symptoms are caused by sexually transmitted infection until proven otherwise
  • Diagnostic tests
    • Chlamydia trachomatis: nucleic acid amplification test is diagnostic
    • Trichomonas vaginalis: wet mount microscopy is usually diagnostic; commercial test kits are available
• Pelvic pain in females
  • Causes
    • Endometriosis
      • Presents with chronic pelvic pain, dysmenorrhea, and/or dyspareunia
      • Bimanual palpation findings may include:
        • Adnexal tenderness
        • Cul de sac nodularity
        • Rectovaginal septum induration
        • Adnexal mass
      • Pelvic sonogram is often diagnostic, but additional imaging and laparoscopy for tissue diagnosis may be necessary
    • Ectopic pregnancy
      • Presents with abdominal and pelvic pain
      • Bimanual palpation reveals adnexal tenderness and usually a palpable adnexal mass
      • Positive pregnancy test result
      • Transvaginal sonogram is often diagnostic
      • May occur concurrently with gonococcal pelvic inflammatory disease and cause diagnostic confusion
        • If there is diagnostic confusion
          • Consider quantitative hCG levels
          • Patient may require laparoscopy
    • Ruptured ovarian cyst
      • Presentation varies depending on type and size of cyst
        • Mild pelvic pain: likely follicular cyst
        • Severe pelvic pain: likely large corpus luteum cyst or endometrioma
      • Adnexal torsion may occur with large cysts and cause severe pelvic pain with peritoneal signs
      • Bimanual palpation findings vary; there may be only slight tenderness
      • Sonography and/or CT help clarify diagnosis
    • Acute appendicitis
      • Initially presents as periumbilical pain; later localizes to lower right quadrant
      • If appendix is pelvic or retrocecal, symptoms may be localized to pelvis
      • Fever and elevated WBC count may be present in both pelvic inflammatory disease and acute appendicitis
      • CT helps clarify diagnosis
    • Renal calculus
      • Presents with colicky pain along pathway of the ureter; patient may describe pain as being in flank, pelvis, or groin
      • Pain is generally severe; patient is usually agitated and unable to sit still
      • Hematuria is present; patient may pass calculi
      • Helical CT helps clarify diagnosis

Treatment Goals

• Eradicate infection and prevent complications
• Treat sex partners
• Counsel and educate patient about prevention of sexually transmitted infections

Disposition

Admission criteria

Severe pelvic inflammatory disease requiring IV antibiotics 

• Nausea and vomiting, high fever, or toxic appearance
• Tubo-ovarian abscess
• Pregnancy
• Failure to respond to outpatient oral therapy
• Inability to follow outpatient regimen

Disseminated gonococcal infection

Criteria for ICU admission

• Pelvic inflammatory disease or ruptured tubo-ovarian abscess with hemodynamic instability or other signs of sepsis

Recommendations for specialist referral

• If persistent infection is documented after treatment, assume treatment failure due to possible antibiotic resistance, which continues to evolve in Neisseria gonorrhoeae
  • Treatment failure requires culture and susceptibility testing for persistent gonorrhea (as well as evaluation for alternative explanations)
  • Refer to infectious disease specialist or contact the National Network STD Clinical Prevention Training Center or the CDC for treatment advice
  • Report the case as being possibly antibiotic resistant to the CDC through local or state health department within 24 hours of diagnosis
• Refer to gynecologist if patient has symptoms of moderate or severe pelvic inflammatory disease
• Refer to urologist if patient has symptoms of severe epididymitis or prostatitis or if symptoms do not resolve rapidly with treatment

Treatment Options

CDC recommends treating uncomplicated urogenital, anorectal, and pharyngeal gonorrhea with a single dose of ceftriaxone 

• If chlamydial infection has not been excluded, doxycycline for 7 days is recommended 
• When ceftriaxone cannot be used to treat urogenital or rectal gonorrhea because patient has a cephalosporin allergy, a single dose of gentamicin plus a single dose of azithromycin is an option 
• If intramuscular ceftriaxone is not available, a single dose of cefixime is an alternative regimen 
  • Cefixime does not provide as high or as sustained bactericidal blood levels as does ceftriaxone, and it demonstrates limited treatment efficacy for pharyngeal gonorrhea
• Alternative antibiotics for pharyngeal gonorrhea are not recommended owing to unreliable efficacy. For patients with a β-lactam allergy, a thorough assessment of the reaction is recommended. For patients with an anaphylactic or other severe reaction to ceftriaxone (eg, Stevens-Johnson syndrome), consult an infectious disease specialist 
• Neisseria gonorrhoeae is evolving high levels of antimicrobial resistance, which threatens the effectiveness of available gonorrhea treatments 

Advise patient to tell all sex partners from the preceding 60 days (or earlier, if no sexual contact in that time frame) that they need to be evaluated and treated for Neisseria gonorrhoeae 

• Tracing and notifying sex partners is done by health departments in most jurisdictions

Consider expedited partner therapy, also known as partner-delivered therapy, if the partner is not a man who has sex with men: 

• Expedited partner therapy: patient delivers oral medication to sex partners without them receiving medical evaluations; other delivery methods have been used (eg, disease investigation specialist, participating pharmacist)
  • Acceptable when the provider believes it likely that the partner(s) cannot or will not seek medical evaluation
• Do not consider this therapy if patient is a man who has sex with men because the partner is at high risk for coexisting sexually transmitted infections that require testing and treatment, including HIV 
• May be prohibited or limited in some states; consult the CDC for updated information about individual jurisdictions 
• Partner may be treated with a single dose of cefixime, provided that concurrent chlamydial infection in the patient has been excluded; otherwise, the partner may be treated with a single cefixime dose plus doxycycline for 7 days 
• Include with prescriptions for expedited partner therapy:
  • Treatment instructions
  • Relevant warnings
  • General health counseling
  • Statement advising partners to seek medical evaluation, especially females who have symptoms of sexually transmitted infections or pelvic inflammatory disease, which can lead to scarring and infertility

Advise patient to avoid sexual contact until 7 days after patient and all sex partners have completed treatment and symptoms have resolved 

Advise patient about safe sex practices to avoid ongoing exposure to sexually transmitted infections 

WHO offers slightly different treatment recommendations based on local antimicrobial susceptibility patterns and availability of resources 

If pelvic inflammatory disease is suspected, initiate treatment rapidly without prolonged diagnostic delay; smoldering infection can cause scarring and lead to infertility

Drug therapy

• Ceftriaxone (for uncomplicated urogenital, anorectal, or pharyngeal infection)
  • Ceftriaxone Sodium Solution for injection; Adolescents weighing less than 150 kg†: 500 mg IM as a single dose.
  • Ceftriaxone Sodium Solution for injection; Adolescents weighing 150 kg or more†: 1 g IM as a single dose.
  • Ceftriaxone Sodium Solution for injection; Adults weighing less than 150 kg: 500 mg IM as a single dose.
  • Ceftriaxone Sodium Solution for injection; Adults weighing 150 kg or more: 1 g IM as a single dose.
  • If chlamydial infection has not been excluded, treatment with oral doxycycline is recommended
• Azithromycin (for patients with severe cephalosporin allergy)
  • Azithromycin Oral tablet; Adults: 2 g PO as a single dose plus gentamicin.
  • During pregnancy, azithromycin 1 g orally as a single dose is recommended to treat chlamydia 
• Gentamicin
  • Gentamicin Sulfate Solution for injection; Children weighing 45 kg or more and Adolescents: 240 mg IM as a single dose plus azithromycin.
  • Gentamicin Sulfate Solution for injection; Adults: 240 mg IM as a single dose plus azithromycin.
• Doxycycline
  • Doxycycline Hyclate Oral capsule; Adults: 100 mg PO every 12 hours for 7 days.
• Cefixime (if ceftriaxone is unavailable, not recommended for pharyngitis) 
  • Cefixime Oral capsule; Children weighing more than 45 kg and Adolescents: 800 mg PO as a single dose.
  • Cefixime Oral capsule; Adults: 800 mg PO as a single dose.
  • For expedited partner therapy, may treat partner with a single 800 mg oral dose of cefixime, provided that concurrent chlamydial infection in the patient has been excluded; otherwise, may treat partner with a single oral 800 mg cefixime dose plus oral doxycycline 100 mg twice daily for 7 days 

Nondrug and supportive care

Procedures

Safe sex counseling

General explanation

• Advise patient to avoid sexual activity until 1 week after both patient and all sex partners have completed drug therapy and all symptoms have resolved 
• Counsel about methods known to decrease risk of sexually transmitted infection: 
  • Abstinence
  • Correct and consistent condom use
  • Limiting number of sex partners
  • Modifying other risky behaviors
  • HPV vaccination for appropriate ages
    • Females up to age 26 years
    • Males up to age 21 years (26 years for men who have sex with men)
• Provide nonjudgmental advice, appropriate to patient’s sex, sexual orientation, age, cultural background, and developmental level 

Indication

• All patients at risk for or diagnosed with gonorrhea or any other sexually transmitted infection

Comorbidities

• Chlamydia trachomatis (urethritis or cervicitis) is the most common sexually transmitted coinfection 
  • If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended 

Special populations

• Pregnant patients are at risk for pregnancy complications and for transmitting infection to the neonate during birth
  • Routine prenatal care
    • Screen at first prenatal visit: 
      • Patients younger than 25 years
      • Patients 25 years and older if other high-risk factors are present (eg, multiple or new sex partners, history of sexually transmitted infection)
    • Rescreen patients with new or ongoing high-risk factors during third trimester 
  • Patients treated for gonorrhea during pregnancy 
    • Administer test of cure within 3 months using a nucleic acid amplification test
    • Retest for gonorrhea in third trimester
  • Complications of untreated gonorrhea
    • Preterm rupture of membranes
    • Preterm labor
    • Chorioamnionitis
    • Transmission of infection to newborn
  • Treat with ceftriaxone in same dosage as for nonpregnant females 
    • During pregnancy, 1 g oral azithromycin as a single dose is recommended to treat chlamydia 
• Neonates
  • CDC strongly recommends all newborns be given prophylactic ocular erythromycin ointment to protect against gonococcal ophthalmia neonatorum 
    • Administration is required by law in many jurisdictions
• Children
  • Diagnosis of gonorrhea in a child indicates probable sexual contact with an infected person. Report immediately to appropriate child protection and law enforcement agencies

Men who have sex with men

• Do not routinely use expedited partner treatment in this population because there is high risk for coexisting sexually transmitted infections, including HIV 

Monitoring

• Perform repeat screening for possible reinfection in all patients 3 months after treatment 
• In patients treated for pharyngeal gonorrhea using an alternative regimen: conduct test of cure by nucleic acid amplification test or culture 7 to 14 days after treatment 
• In patients who do not improve within several days after treatment and who deny interim sexual activity: evaluate for alternate explanations and culture for Neisseria gonorrhoeae
  • Submit positive cultures for antimicrobial susceptibility testing (may require specialty or public health laboratory)
  • Patients in whom initial course of appropriate antibiotics fails: conduct test of cure 7 to 14 days after retreatment 

Complications

• Treatment failure
  • Usually caused by reinfection
    • If cephalosporin-resistance is not suspected, re-treat patient with recommended regimen
  • Suspect cephalosporin-resistant gonorrhea if all of the following are true: 
    • Symptoms do not resolve within 3 to 5 days
    • There has been no sexual contact during the posttreatment follow-up period
    • Positive test of cure result
      • Positive culture result 72 hours or more after treatment
      • Positive nucleic acid amplification test result 7 days or more after treatment
  • If cephalosporin-resistance is suspected:
    • Consult with infectious disease specialist to guide therapy
    • Report to CDC through local or state health department within 24 hours of diagnosis
• Pelvic inflammatory disease
  • Occurs in 10% to 20% of patients with gonococcal cervicitis 
  • Acutely, may result in:
    • Fallopian tube infection
    • Tubo-ovarian abscess
    • Endometritis
    • Peritonitis
  • May spread and cause perihepatitis (Fitz-Hugh-Curtis syndrome)
  • Gold standard diagnostic criteria include 1 or more of the following:
    • Laparoscopy with visual evidence of tubal involvement
    • Endometritis proved with biopsy
    • Thickened, fluid-filled fallopian tubes seen on transvaginal ultrasonography
  • Start empiric treatment of pelvic inflammatory disease without delay if the following nondefinitive criteria are met:
    • Pelvic or lower abdominal pain in patient at risk for pelvic inflammatory disease
    • 1 or more of the following is evident on pelvic examination:
      • Uterine tenderness
      • Adnexal tenderness
      • Cervical motion tenderness
    • These signs increase probability of pelvic inflammatory disease diagnosis: 
      • Fever higher than 38.3 °C 
      • Mucopurulent vaginal or cervical discharge
      • Positive test result for gonorrhea, chlamydia, or both
      • WBCs seen on microscopy of vaginal secretions
    • Recommended outpatient treatment regimen: 
      • Ceftriaxone (or cefoxitin plus probenecid) plus doxycycline, with or without metronidazole
        • Ceftriaxone Sodium Solution for injection; Adults: 250 mg IM as single dose with doxycycline PO for 14 days with or without metronidazole PO for 14 days.
        • Cefoxitin Sodium Solution for injection; Adults and Adolescents: CDC recommends 2 g IM as single dose plus probenecid 1 g PO plus oral doxycycline with or without oral metronidazole for 14 days for outpatients with mild to moderate PID.
        • Doxycycline Hyclate Oral capsule; Adults and Adolescents†: CDC recommends 100 mg PO every 12 hours for 14 days.
        • Metronidazole Oral tablet; Adults females: 500 mg PO twice daily with doxycycline for 14 days plus single dose ceftriaxone IM, cefoxitin IM plus probenecid, or other parenteral third generation cephalosporin recommended by CDC for mild-to-moderate PID.
    • Recommended inpatient treatment regimens for patients too ill to tolerate outpatient treatment, those with tubo-ovarian abscess, and those who are pregnant: 
      • Cefoxitin or cefotetan plus doxycycline
        • Cefoxitin Sodium Solution for injection; Adults: CDC recommends 2 g IV every 6 hours plus doxycycline; cefoxitin continued for at least 24 hours after clinical improvement, then oral doxycycline for 14 days total treatment. For tubo-ovarian abscess, use clindamycin or metronidazole with doxycycline.
        • Cefotetan Disodium Solution for injection; Adults: 1 to 2 g IV every 12 hours for mild to moderate infections, 2 g IV every 12 hours for severe infections, and 3 g IV every 12 hours for life-threatening infections. For PID, clinical guidelines suggest 2 g IV every 12 hours plus doxycycline; cefotetan continued for at least 24 hours after clinical improvement, then oral doxycycline for 14 days total treatment. For tubo-ovarian abscess, use clindamycin or metronidazole with doxycycline.
        • Doxycycline Hyclate Oral capsule; Adults and Adolescents†: CDC recommends 100 mg PO, or IV if necessary, q12h for 14 days with cefotetan or cefoxitin. Use oral route when possible, even in hospitalized patients. Can use oral doxycycline alone after at least 24 hours of clinical improvement. CDC also recommends clindamycin plus gentamicin, followed by doxycycline 100 mg PO q12h to complete 14 days total therapy. Other combinations include ampicillin; sulbactam, ceftriaxone IM, cefoxitin IM plus probenecid, or other parenteral cephalosporins +/- metronidazole.
    • Long-term sequelae:
      • Syndrome of chronic pelvic pain and dyspareunia after treatment
      • Infertility due to tubal scarring
      • Ectopic pregnancy due to tubal scarring
• Gonococcal epididymitis
  • Potential complications if untreated include chronic pain and infertility
  • Treat with ceftriaxone, plus oral course of doxycycline if chlamydia infection not ruled out 
    • Ceftriaxone Sodium Solution for injection; Adults, Adolescents: 500 mg IM (1 g for patients weighing 150 kg or more) as single dose with oral doxycycline (for chlamydia) for 10 days when most likely caused by gonorrhea and chlamydia. When likely caused by gonorrhea, chlamydia, and enteric organisms, ceftriaxone 500 mg IM (1 g for patients weighing 150 kg or more) as single dose plus levofloxacin. 
• Gonococcal conjunctivitis
  • May occur in adults owing to autoinoculation
  • Treat with ceftriaxone, plus oral course of doxycycline if chlamydia infection is not ruled out 
    • Ceftriaxone Sodium Solution for injection; Adults: 1 g IM as a single dose.
  • Consult with infectious disease specialist to guide treatment
• Gonococcal ophthalmia neonatorum
  • May occur in infants born to infected mothers
  • Treat with ceftriaxone
    • Ceftriaxone Sodium Solution for injection; Neonates: 25 to 50 mg/kg/dose (Max: 125 mg/dose) IV/IM as a single dose.
• Disseminated disease (gonococcemia)
  • Most commonly causes arthralgias and tenosynovitis, septic arthritis, and, very rarely, endocarditis or meningitis
    • Recommended: hospitalize patient to initiate therapy, especially in cases of diagnostic uncertainty or in those patients with septic arthritis
    • Perform blood cultures and echocardiography to look for evidence of endocarditis
    • Consider lumbar puncture if there is evidence of meningitis
    • Initial treatment of arthralgias/arthritis/tenosynovitis is with a single dose of azithromycin, plus ceftriaxone; ceftriaxone is continued for 48 hours after clinical improvement. Continue treatment with an oral agent guided by antimicrobial susceptibility testing to complete at least 1 week of antimicrobial therapy. 
      • Ceftriaxone Sodium Solution for injection; Adults: 1 g IV/IM every 24 hours until 24 to 48 hours after clinical improvement then switch to an oral agent for a total of 7 days plus azithromycin.
      • Azithromycin Oral tablet; Adults: 1 g PO as a single dose plus ceftriaxone.
    • Treatment of endocarditis/meningitis is with ceftriaxone for 10 to 14 days (meningitis) or 4 weeks (endocarditis) 
      • Ceftriaxone Sodium Solution for injection; Adults: 2 g IV every 24 hours. 
• Gonorrhea can facilitate HIV transmission in all patients owing to associated mucosal erosion and tissue friability

Prognosis

• Males: good with appropriate antibiotic treatment
• Females: good if treated early with appropriate antibiotics before progression to pelvic inflammatory disease
  • Untreated gonococcal genitourinary infection can lead to fallopian tube scarring, infertility, chronic pelvic pain, and ectopic pregnancy

Screening

At-risk populations

• US Preventive Services Task Force recommendations
  • Routine annual screening for gonorrhea (and chlamydia) in all asymptomatic, sexually active females (including pregnant patients) at high risk, defined as follows: 
    • Aged 24 years or younger
    • Aged 25 years or older with new or continued risk factors:
      • History of previous gonorrhea or other sexually transmitted infections
      • New or multiple sex partners
      • Inconsistent condom use
      • Sex work
      • Drug use
      • Living in communities with a high prevalence of disease
  • Insufficient evidence to recommend screening in females at low risk, regardless of pregnancy status
  • Insufficient evidence to recommend for or against screening in men
• CDC recommends routine screening for these populations:
  • Incarcerated people:
    • Screen adolescent and adult females aged 35 years or younger at intake into juvenile detention or jail facilities
    • Screen adolescent and adult males aged 30 years or younger at intake into juvenile detention or jail facilities
  • Men who have sex with men
    • Test those who have had insertive intercourse during the preceding year for urethral Neisseria gonorrhoeae (and Chlamydia trachomatis) infection
    • Test those who have had receptive anal intercourse during the preceding year for rectal Neisseria gonorrhoeae (and Chlamydia trachomatis) infection
    • Test males who have had receptive oral intercourse during the preceding year for pharyngeal infection with Neisseria gonorrhoeae; testing for Chlamydia trachomatis pharyngeal infection is not recommended

Screening tests

• Females
  • Use FDA-approved nucleic acid amplification tests for urine and endocervical specimens 
  • Some nucleic acid amplification tests are approved specifically for clinician and/or patient-collected vaginal swabs 
  • Nucleic acid amplification tests have higher screening sensitivity and comparable specificity compared with cervical culture 
• Men who have sex with men
  • Nucleic acid amplification tests have high sensitivity and specificity 
  • Urine nucleic acid amplification tests are recommended for urethral gonorrhea 
  • Nucleic acid amplification testing of swabs is recommended for rectal or pharyngeal testing 

Prevention

• US Preventive Services Task Force recommends that the following groups receive behavioral counseling about prevention of sexually transmitted infections: 
  • All sexually active adolescents
  • Adults who are at increased risk for sexually transmitted infections, including those who:
    • Have a new sex partner
    • Have multiple sex partners
    • Do not use condoms consistently
    • Have a current sexually transmitted infection
    • Have had a sexually transmitted infection within the past year
    • Are men who have sex with men
• Prevention of sexually transmitted gonorrhea
  • Abstinence
  • Reduce number of sex partners
  • Use latex condoms
    • For patients with latex allergy: polyurethane and other synthetic materials provide protection but are more likely to break than latex
    • Natural membrane condoms are not recommended
    • Use only water-based lubricants
    • Little research is available about sexually transmitted infection prevention provided by female condoms
• Prevention of ophthalmia neonatorum in all infants
  • Ophthalmic antibiotic ointment (1% silver nitrate aqueous solution, 0.5% erythromycin ophthalmic ointment, or 1% tetracycline ointment) should be instilled into the eyes of all newborns 
    • Erythromycin preparation only is available in the United States
• Prevention of gonococcal infection in infants born to mothers with untreated gonorrhea 
  • Single dose ceftriaxone

References

1: St Cyr S et al: Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 69(50):1911-1916, 2020 Reference