Emergent Management of Gonorrhea
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In emergency department (ED) patients who clinical presentation suggests gonorrhea, specimens from likely sites of infection should be sent to the laboratory to be cultured for N gonorrhoeae and Chlamydia species. Nucleic acid amplification tests (NAATs) may be used in addition to or in place of culture depending on availability and laboratory preferences. [1] The possibility of other sexually transmitted diseases (STDs) should be evaluated.
Begin appropriate antibiotic therapy for gonorrhea as soon as possible. Chlamydial infection is found frequently in patients with gonorrhea; thus, empiric antibiotic therapy should always provide coverage for both infections in any patients other than newborns. Gonococcal infection in HIV-positive patients is treated with the same regimen used for the general population.
Pain relief may be needed for patients with epididymitis, pelvic inflammatory disease, and disseminated gonococcal infection (DGI). Aspiration of purulent joint effusions may improve the patient’s comfort and recovery.
Partner diagnosis and treatment is important to prevent reinfection and complications. Counsel patients to abstain from sexual activity until after full treatment and testing and treatment of partners is complete. Patients should receive information and counseling to help them avoid future STDs and unwanted pregnancies.
Social services should be consulted immediately in cases of suspected sexual assault, child abuse, or elder abuse. Clinicians should be aware, however, that gonorrhea can be transmitted to children nonsexually (eg, spread of infection can occur via contaminated hands of infected caregivers). [2]
For more information, see the Medscape Reference topic Gonorrhea.
Consult a gynecologist for patients with severe pelvic inflammatory disease and for any pregnant patient with a sexually transmitted infection (STD). Consult a pediatrician for any child with an STD.
Consult an ophthalmologist for every patient with gonococcal conjunctivitis (see image below). This disease may progress rapidly and can cause permanent loss of vision.
Because of resistance with oral cephalosporins, only 1 regimen, dual treatment with ceftriaxone IM and azithromycin PO, is recommended for treatment of gonorrhea in the United States. Dual therapy with ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously and under direct observation. In addition, persons infected with N gonorrhoeae frequently are coinfected with C trachomatis; this finding has led to the longstanding recommendation that persons treated for gonococcal infection also be treated with a regimen that is effective against uncomplicated genital C trachomatis infection, further supporting the use of dual therapy that includes azithromycin. [3]
Because of the persistent increase in multidrug-resistant gonorrhea, the CDC 2015 recommendations’ preferred dual-drug regimen consists of the following: [4]
The 250-mg IM dose of ceftriaxone is recommended over the 125-mg dose, given concern for resistance, prior lower-dose ceftriaxone dose failures, and seemingly improved efficacy in pharyngeal infections. Ceftriaxone is safe and effective in pregnant women and probably destroys incubating syphilis. Its major drawback is the necessity for IM administration.
Since 2007, the Centers for Disease Control and Prevention (CDC) has not recommended fluoroquinolone antibiotics for the treatment of gonorrhea in the United States because of bacterial resistance.
In August 2012, the CDC announced changes to 2010 sexually transmitted disease guidelines for gonorrhea treatment. The Gonococcal Isolate Surveillance Project (GISP) described a decline in cefixime susceptibility among urethral N gonorrhoeae isolates in the United States during 2006-2011. Because of cefixime’s lower susceptibility, new guidelines were issued that no longer recommend oral cephalosporins for first-line gonococcal infection treatment. [5]
If ceftriaxone is unavailable, patients can be given a single dose of cefixime 400 mg PO plus a single dose of azithromycin 1 g PO.
If cephalosporin allergic, consider alternant dual therapy with single doses of gemifloxacin PO 320 mg plus azithromycin 2 g PO, or gentamicin 240 mg IM plus azithromycin 2 g PO.
Another alternative regimen for patients intolerant of cephalosporins is spectinomycin (2 g IM). Spectinomycin may be costly and is currently unavailable in the United States.
If azithromycin allergic, doxycycline (100 mg PO BID for 7 days) can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone (preferably) or cefixime.
Although cephalosporins remain an effective treatment for gonococcal infections, the CDC has reported that resistance to cefixime increased from 0.2% in 2000 to 1.4% in 2010 and back down to 0.4% in 2013, and resistance to ceftriaxone increased from less than 0.1% to 0.4% in 2011 and back down to 0.05% in 2013. [4] However, the reported rates of resistance to ceftriaxone have been much higher in countries such as Japan, Spain, and France. [4] Oral cephalosporins are no longer recommended as first-line treatment for gonorrhea because of increasing resistance. Additionally, a high prevalence of tetracycline resistance among GISP isolates was observed, particularly among patients with elevated MICs to cefixime. [5]
Spectinomycin (Trobicin) is indicated for patients with beta-lactam intolerance. It is a second-line choice due to poor efficacy in pharyngitis. This drug is currently unavailable in the United States.
A review of the literature identified trials using single-dose gentamicin, an aminoglycoside, in the treatment of uncomplicated gonococcal infections in patients older than 16 years owing to the increase in antibiotic resistance. Although the primary outcome was the microbiological cure of N gonorrhoeae infection, further randomized trials are indicated. [6]
For more information see, CDC Sexually Transmitted Diseases Treatment Guidelines, 2015.
Hospitalization is recommended for initial treatment of disseminated gonococcal infection (especially for patients who are unlikely to return for follow-up doses of antibiotics), purulent joint infections, meningitis, and endocarditis. [4]
Hospitalization is recommended for initial treatment of pelvic inflammatory disease (PID) cases in the presence of the following factors:
Tubo-ovarian abscess
Pregnancy
Failure of outpatient treatment
Severe symptoms, such as severe pain, high fever, or persistent nausea and vomiting
Immunodeficiency
Gonococcal conjunctivitis (see image below)
Uncertain diagnosis, with any possibility of ectopic pregnancy or appendicitis masquerading as PID
Abdominal peritonitis or perihepatitis
Patients with disseminated gonococcal infection or pelvic inflammatory disease who are treated on an outpatient basis must receive follow-up care within 72 hours. Early follow-up care and culture with antibiotic sensitivities is indicated for patients with unresolved or recurrent symptoms.
Follow-up for test of cure is indicated for all pharyngitis cases treated with spectinomycin, as its efficacy is less than 60%.
Recurrent symptoms may result from re-infection rather than treatment failure. However, if treatment failure is suspected, culture of isolates is recommended. [4]
Instruct patients with uncomplicated cases to follow up with a primary care or public health provider to reduce the risk of future infection.
All patients with gonococcal infection should refer all their sex partners (whether symptomatic or asymptomatic) for evaluation and treatment.
All infants born to mothers with untreated gonococcal infection should be treated prophylactically with a single dose of ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 mg. All neonates should undergo prophylaxis for ophthalmia neonatorum with silver nitrate (1%) aqueous solution OU once or erythromycin (0.5%) ophthalmic ointment OU once.
Condoms offer partial protection against gonococcal infection and should be recommended. [7]
Whiley DM, Tapsall JW, Sloots TP. Nucleic acid amplification testing for Neisseria gonorrhoeae: an ongoing challenge. J Mol Diagn. 2006 Feb. 8(1):3-15. [Medline]. [Full Text].
Goodyear-Smith F. What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forensic Leg Med. 2007 Nov. 14(8):489-502. [Medline].
Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Gonococcal Infections. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/tg2015/gonorrhea.htm. June 4, 2015; Accessed: March 23, 2016.
Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections. MMWR Morb Mortal Wkly Rep. 2012 Aug 10. 61:590-4. [Medline]. [Full Text].
Hathorn E, Dhasmana D, Duley L, Ross JD. The effectiveness of gentamicin in the treatment of Neisseria gonorrhoeae: a systematic review. Syst Rev. 2014 Sep 19. 3(1):104. [Medline].
Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. 2006 Jan. 33(1):36-51. [Medline].
Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates — United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2011 Jul 8. 60(26):873-7. [Medline].
[Guideline] Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].
Golden MR, Barbee LA, Kerani R, Dombrowski JC. Potential Deleterious Effects of Promoting the Use of Ceftriaxone in the Treatment of Neisseria gonorrhoeae. Sex Transm Dis. 2014 Oct. 41(10):619-25. [Medline].
Golparian D, Ohlsson A, Janson H, Lidbrink P, Richtner T, Ekelund O, et al. Four treatment failures of pharyngeal gonorrhoea with ceftriaxone (500 mg) or cefotaxime (500 mg), Sweden, 2013 and 2014. Euro Surveill. 2014 Jul 31. 19(30):[Medline].
Availability of cefixime 400 mg tablets–United States, April 2008. MMWR Morb Mortal Wkly Rep. 2008 Apr 25. 57(16):435. [Medline].
Centers for Disease Control and Prevention. 2009 Sexually transmitted diseases surveillance: gonorrhea. Available at http://www.cdc.gov/STD/stats09/gonorrhea.htm. Accessed: 5/27/11.
Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School
Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Amy J Behrman, MD Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, Perelman School of Medicine at the University of Pennsylvania
Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Physicians
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Consultant for Sanofi, Influenza Vaccine Branch.
Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Catherine T Shoff, DO Staff Physician, Departments of Pulmonary, Critical Care and Sleep Medicine, Director, Tri-Services Adult Cystic Fibrosis Center, Wilford Hall Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Catherine T Shoff, DO is a member of the following medical societies: American Academy of Sleep Medicine and American College of Chest Physicians
Disclosure: Nothing to disclose.
Emergent Management of Gonorrhea
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