Gonorrhea
Cheryl A. Glass and Leslie B. Norman
Definition
A.Gonorrhea is a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae organism.
Incidence
A.The World Health Organization (WHO) estimates more than one million STI are acquired every day worldwide. Each year, there are an estimated 357 million new infections with one of four STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis. Gonorrhea is the second most commonly reported communicable disease.
B.Testing and screening recommendations:
1.Screening for gonorrhea in men and older women who are at low risk for infection is not recommended.
2.Annual screening is recommended in older patients who have a new sex partner, more than one sex partner, or a partner who has other partners or an STI.
3.Males:
a.Screen at least annually for sexually active men having sex with men (MSM) regardless of condom use.
b.Every 3 to 6 months is indicated for MSM at increased risk:
i.Concurrent HIV infection if risk behaviors persist.
ii.If they or their sexual partners have multiple partners.
4.Females:
a.The primary focus of a screening should be to detect gonorrhea, to prevent complications such as pelvic inflammatory disease (PID), and to test and treat partners:
i.Annual screening of all sexually active women age less than 25 years is recommended.
ii.Screen older women (>25 years) at increased risk for infection:
•New sex partner.
•More than one sex partner.
•Sex partner with concurrent partners.
•Sex partner who has a STI.
Pathogenesis
A.N. gonorrhoeae, a gram-negative diplococcus, is the causative organism. The infection begins with adherence of N. gonorrhoeae to the mucosal cells in the genitourinary tract or endocervix. The incubation period is typically 2 to 5 days for urethritis and 5 to 10 days for cervical infection.
B.Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials.
Predisposing Factors
A.History of STIs.
B.New partner or one who is not monogamous.
C.Trading sex for drugs or money.
D.Multiple sexual partners.
E.Early age at first coitus:
1.Unprotected intercourse.
2.Inconsistent condom use.
3.Gay.
4.Bisexual.
5.MSM (high risk for gonorrhea).
6.Factors contributing to increase of STIs in older adults:
a.Undereducated: Older adults are less likely to perceive themselves at risk. Safe sex and STI prevention education came in the 1980s dealing with the HIV crisis during the time older adults were middleaged and married. Seniors may feel sex education is directed only to youth and prevention of pregnancy.
b.Medications for erectile dysfunction have contributed to more men being able to engage in sexual activity throughout their older years.
c.Online dating lowers the chance that partners know the background and sexual history of people they date.
d.Women are postmenopausal and do not worry about getting pregnant with new partners.
Common Complaints
A.Dysuria.
B.Yellow, white, or mucoid urethral discharge in males.
C.Greenish, irritating vaginal discharge in females.
D.Menstrual irregularities.
E.Pelvic pain.
F.Fever.
Other Signs and Symptoms
A.Asymptomatic, including rectal and pharyngeal.
B.Uterine or adnexal tenderness.
C.Mucopurulent discharge from endocervix.
D.Polyarthralgias.
E.Necrotic skin lesions.
Subjective Data
A.Elicit history of onset, duration, and location of symptoms. Note aggravating and alleviating factors and associated symptomatology.
B.Question the patient about sexual partners, history of other STIs, and sexual habits including anal and oral sexual exposure.
C.The Centers for Disease Control and Prevention (CDC) recommends a recent travel history with sexual contacts outside of the United States should be part of any gonorrhea evaluation.
Physical Examination
A.Check temperature (if indicated).
B.Inspect:
1.Inspect the skin for necrotic skin lesions.
2.Oral examination.
3.Males: Inspect for anal and/or urethral discharge; elicit latter by milking penis.
4.Females:
a.Inspect anus and introitus for discharge; milk urethra.
b.Speculum exam: Inspect vaginal walls and cervix for discharge and irritation.
C.Palpate:
1.Examine joints for effusion and swelling.
2.Males: Palpate inguinal lymph nodes.
3.Females:
a.Palpate inguinal lymph nodes.
b.Palpate periurethral and Bartholin glands for exudate.
c.Bimanual exam:
i.Assess for cervical motion, tenderness, and friability.
ii.Assess for uterine and adnexal tenderness.
Diagnostic Tests
It is important to obtain a thorough sexual history from the patient and to screen all orifices used during sexual contact (i.e., oropharynx, rectum).
A.Culture samples from the endocervical urethral (men only): rectum culture is also available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection:
1.Use Dacron-tipped applicator for Genprobe culture.
2.Obtain endocervix culture samples by rotating swab in endocervix for a full 30 seconds.
B.Nucleic acid amplification test (NAAT) allows for the widest variety of FDA-cleared specimen types, including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (both men and women):
1.NAAT is not Food and Drug Administration (FDA)-cleared for rectal, oropharyngeal, and conjunctival gonococcal infection.
2.NAATs are FDA-cleared for use with vaginal swab specimens collected by a provider or self-collected in a clinical setting. Self-collected vaginal swab specimens are equivalent in sensitivity and specificity to collection by providers.
Optimal urogenital specimen types for chlamydia screening using NAAT include:
a.Men: First catch urine.
b.Women: Vaginal swabs:
i.NAATs are not FDA-cleared for use with rectal or oropharyngeal swab specimens.
ii.Some NAATs have been FDA-cleared for use on liquid-based cytology specimens.
C.For persons diagnosed with gonorrhea, testing should also be performed for chlamydia, syphilis, and HIV.
D.In cases of suspected or documented treatment failure, both cultures and antimicrobial susceptibility testing are needed because nonculture tests cannot provide antimicrobial susceptibility results.
E.During septic joint stage, gonococci can be recovered from the joint by aspiration for culture.
Differential Diagnoses
A.Gonorrhea.
B.Chlamydia.
C.Arthritis (rheumatoid or septic).
D.Nongonococcal urethritis (NGU).
E.Mycoplasma genitalium.
Plan
A.General interventions:
1.Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials:
a.In 2007, emergence of fluoroquinolone-resistant N. gonorrhoeae in the United States prompted the CDC to cease recommending fluoroquinolones for treatment of gonorrhea, leaving cephalosporins as the only remaining class of antimicrobials available for treatment of gonorrhea in the United States.
b.The CDC no longer recommends the routine use of cefixime as a first-line regimen for the treatment of gonorrhea in the United States.
c.In addition, U.S. gonococcal stains with elevated minimal inhibitory concentration (MIC) to cefixime are also likely to be resistant to tetracyclines but susceptible to azithromycin.
2.All persons who receive a diagnosis of gonorrhea should be tested for other STIs, including chlamydia, syphilis, and HIV.
3.Report positive test results to the health department.
B. 
See Section III: Patient Teaching Guide Gonorrhea
:
1.Stress the importance of completing the medication regimen.
2.Inform the patient of the need for partner notification and treatment. Notification is recommended for any partner with whom the patient has had sexual contact within 60 days of the onset of symptoms.
3.Advise the patient to avoid sexual intercourse after single-dose therapy or until treatment completion and for 7 more days following the last day of antibiotic treatment and resolution of symptoms, if present.
4.Repeat infections place women at an elevated risk for PID and other complications.
5.Persons who have gonorrhea and HIV infection should receive the same treatment regimen as those who are HIV negative.
C.Pharmaceutical therapy:
1.Uncomplicated gonococcal infections of the cervix, urethra, and rectum:
a.Ceftriaxone 250 mg by intramuscular (IM) injection of a single dose PLUS azithromycin 1 g orally in a single dose.
b.It is preferable that the dual therapy of ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously under direct observation.
c.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.
2.Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum:
a.If ceftriaxone is not available, Cefixime 400 mg by mouth in a single dose PLUS azithromycin 1 g orally in a single dose OR
b.Single-dose injectable cephalosporin plus azithromycin 1 g orally single dose or doxycycline 100 mg orally twice daily for 7 days.
3.For patients with severe allergy to cephalosporins or immunoglobulin E (IgE)-mediated penicillin allergy, the CDC recommends consulting with an infectious disease specialist though it notes azithromycin 2 g dose orally PLUS oral gemifloxacin 320 mg as a single dose as a potential therapeutic alternative.
4.Uncomplicated gonococcal infections of the pharynx:
a.Recommended regimen: Ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose.
5.Treatment for gonococcal conjunctivitis, disseminated gonococcal infection, treatment of arthritis and arthritis-dermatitis syndrome, and gonococcal meningitis and endocarditis is located on the CDC website: www.cdc.gov/std/tg2015/gonorrhea.htm.
Follow-Up
A.The CDC no longer recommends a test of cure for a diagnosis of uncomplicated urogenital or rectal gonorrhea treated with the recommended or alternative regimens; however, any person with pharyngeal gonorrhea who is treated with an alternative regimen should return in 14 days after treatment for a test-of-cure using either culture or NAAT. If the NAAT is positive, efforts should be made to perform a confirmatory culture before retreatment.
B.All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing.
C.All individuals should be closely monitored for treatment failure/reinfection caused by failure of sex partners to receive treatment or initiation of sexual activity with a new infected partner.
D.Men and women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated. If retesting at 3 months is not possible, clinicians should retest whenever they present for medical care within 12 months following initial treatment.
E.Providers are advised to report all treatment failures to the local or state public health department within 24 hours.
Consultation/Referral
A.Consult with a physician or refer the patient if treatment with the recommended dosage fails and patient noncompliance and reexposure have been ruled out.
Individual Considerations
A.Pregnancy: