Guidelines 2016 – Gonorrhea
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Gonorrhea is a sexually transmitted bacterial infection of the urethra, rectum, and/or cervix; the causative organism can also be cultured in the nasopharynx. As many as 80% of infected women may be asymptomatic.
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II. ETIOLOGY
The causative organism is N. gonorrhoea, a gram-negative, intracellular, nonmotile diplococcus. Plasmid-mediated penicillinase-producing N. gonorrhoea (PPNG), plasmid-mediated tetracycline-resistant N. gonorrhoea (TRNG), chromosomally mediated resistant N. gonorrhoea (CMRNG), spectinomycin-resistant, and quinolone-resistant strains exist. Incubation period is 1 to 13 days.
III. HISTORY
A. What the patient may present with
1. Females: A large percentage (perhaps 80%) of infected women are asymptomatic in the early disease stage.
a. Early symptoms
i. Dysuria, dyspareunia
ii. Leukorrhea; change in vaginal discharge
iii. Unilateral labial pain and swelling
iv. Lower abdominal discomfort
v. Pharyngitis
b. Later symptoms
i. Purulent, irritating vaginal discharge
ii. Fever (possibly high)
iii. Rectal pain and discharge
iv. Abnormal menstrual bleeding
v. Increased dysmenorrhea
vi. Nausea, vomiting
vii. Lesions in genital area; labia pain
viii. Joint pain and swelling
ix. Upper abdominal pain (perihepatitis)
x. Pain, tenderness in pelvic organs; urethral pain
2. Males: usually symptomatic (up to 10% asymptomatic)
a. Early symptoms
i. Dysuria with frequency
ii. Whitish discharge from penis
iii. Pharyngitis
b. Later symptoms
i. Yellow or greenish discharge from penis
ii. Epididymitis
iii. Proctitis
B. Additional information to be considered
1. Age of the woman is younger than 25 years
2. Previous vaginal infections, diagnosis, and treatment
3. Chronic illness
4. Sexual activity: number, new sexual partner(s)
5. History of STI or PID
6. Known contact
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7. Last intercourse, sexual contact
8. Method of birth control, other medications
9. History of cervical ectopy, friability in known patient
10. Postcoital bleeding
11. Description of discharge
a. Onset
b. Color
c. Odor
d. Consistency
e. Amount
f. Relationship to sexual contact
12. Any change in menses (increased flow or dysmenorrhea)
13. Any drug allergies
14. HIV risk or exposure
15. Travels to Asia, Africa, the Pacific, U.S. West Coast
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Blood pressure
2. Temperature
3. Pulse
B. Abdominal examination
1. Guarding
2. Referred pain
3. Rebound pain
4. Upper bilateral quadrant pain
5. Bowel sounds indicating intestinal hyperactivity
C. External examination
1. Inspection of Skene’s glands
2. Inspection of urethra
3. Inspection of Bartholin’s glands
D. Vaginal examination (speculum)
1. Vaginal walls: discharge, redness
2. Cervix: mucopurulent discharge, ectopy, friability
3. Vaginal discharge
E. Bimanual examination
1. Pain when cervix is moved by examiner
2. Uterine tenderness
3. Adnexal tenderness
4. Adnexal mass
F. Throat examination
1. Erythema, including tonsils
2. Edema of posterior pharynx
3. Erythema
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V. LABORATORY EXAMINATION
A. GC culture, nucleic acid hybridization tests, or NAATs from oral, endocervical, vaginal, and/or rectal swabs. Note that nonculture tests do not provide antimicrobial susceptibility data.
B. If positive for gonorrhea and/or by history and risk factors, test for syphilis, Chlamydia, and HIV.
VI. DIFFERENTIAL DIAGNOSIS
A. Chlamydia infection
B. Appendicitis
C. Ectopic pregnancy
VII. TREATMENT
A. Recommended regimen
1. Ceftriaxone 250 mg IM in a single dose, plus, Azithromycin 1g orally in a single dose
a. As dual therapy, ceftriaxone and azithromycin should be administered together on the same day, preferably simultane- ously and under direct observation. Ceftriaxone, in a single injection of 250 mg, provides sustained, high bacterial levels in the blood. Extensive clinical experience indicates that ceftri- axone is safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of uncomplicated urogenital and anorectal and 98% of pharyngeal infections in clinical tests. 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 ano- rectal gonococcal infections include ceftrizomine (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 infections, and efficacy for pharyngeal infection is less certain. Several other antimicrobials are active against N. gonorrhoeae, but none have substantial advantages over the recommended regimen, and efficacy data (especially for pharyngeal infection) are limited.
2. Alternative regimens (if ceftriaxone is not available)
a. Cefixime 400 mg orally in a single dose, plus, Azithromycin 1 g orally in a single dose
3. For contacts: verify if partner had diagnosed infection; after appropriate culture, treat with same regimen as the patient depending on history of sensitivities
B. General measures
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1. All sexual partners should be treated if last sexual contact was within 60 days of onset of symptoms in patient or diagnosis of infection. If beyond 60 days, treat patient’s most recent sexual partner.
2. For heterosexual patients whose partners’ treatment cannot be ensured, consider delivery of therapy for gonorrhea and Chlamydia infection by the patients to their partners, along with efforts to educate partners about symptoms and to encourage them to seek evaluation. For male patients whose partners are female, include educational materials about seeking evaluation for PID.
3. No intercourse until both partners are treated or use condoms, but abstinence is preferred
4. Stress the importance of completing medication
5. Stress personal hygiene
6. Stress need for follow-up culture if symptoms persist, recur, or exacerbate
VIII. COMPLICATIONS
A. Females
1. Pelvic inflammatory disease
a. Pelvic abscess or Bartholin’s abscess
b. Infertility
2. Disseminated gonococcal infection: gonococcal bacteremia
3. In pregnancy: spontaneous abortion, premature rupture of membranes, premature delivery, chorioamnionitis
B. Males
1. Proctitis
2. Infertility caused by epididymitis, prostatitis, and/or seminal vesiculitis
3. Urethral stricture
4. Disseminated gonococcal infection—gonococcal bacteremia
C. Newborns: ophthalmia neonatorum, sepsis, arthritis, meningitis, rhinitis, urethritis, vaginitis, inflammation at sites of fetal monitoring
D. Males and females
1. Meningitis
2. Endocarditis
3. Gonococcal conjunctivitis
IX. CONSULTATION/REFERRAL
A. If no response to treatment as discussed previously
B. If complications develop
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X. FOLLOW-UP
A. Test of cure not recommended by the CDC (2014) unless symptoms recur, exacerbate, or do not resolve
B. Most infections are reinfections, not treatment failures
C. Serology test for syphilis in 30 days
D. Chlamydia test if not done at initial visit prior to treatment
E. Consider HIV and hepatitis B and C screening
F. If symptoms persist after treatment, then evaluate by culture for
N. gonorrhoeae and test any gonococci for antimicrobial susceptibility
Appendix I has information about gonorrhea that you can photocopy or adapt for your patients.
See Bibliographies.
Websites: www.cdc.gov/std/treatment/2010; www.cdc.gov/mmwr/pdf/rr/rr5912.pdf