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{{Gonorrhea}}
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==Overview==
==Overview==
'''Gonorrhea''' ('''gonorrhoea''' in British English) is amongst the most common [[sexually transmitted disease]]s in the world and is caused by [[Gram-negative]] [[Bacteria|bacterium]] ''[[Neisseria gonorrheae]]''. The term comes from Ancient Greek γονόρροια (''gonórrhoia''), literally "flow of seed"; in ancient times it was incorrectly believed that the [[pus]] discharge associated with the disease contained semen.<ref>[http://www.yourdictionary.com/ahd/g/g0191000.html Definition of the term gonorrhea]</ref>
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].  Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.
<gallery>
Image:PenicillinPSAedit.jpg|Gonorrhea treatment advertisement from 1944, when penicillin became widely available due to mass production.
</gallery>
=== Acute Pharmacotherapies ===


Several antibiotics can successfully cure gonorrhea in adolescents and adults. However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States, and successful treatment of gonorrhea is becoming more difficult. Because many people with gonorrhea also have chlamydia, another sexually transmitted disease, antibiotics for both infections are usually given together. Persons with gonorrhea should be tested for other STDs.
==Medical Therapy==


It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.
*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 &#124; MMWR |format= |work= |accessdate=}}</ref>


The mainstay of treatment is the appropriate use of [[antibiotic]]s. While penicillin was the most common antibiotic used to treat gonorrhea up until the 1970s, an increase in antibiotic resistance has led to a decline in its use. Recommendations for first choice treatment of gonorrhea must depend on local information on resistance patterns and it is not possible to make treatment recommendations that are applicable to all parts of the world.
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" |<br />


The [[Centers for Disease Control and Prevention]] (CDC) released a report on Thursday, April 12, 2007 officially adding gonorrhea to a list of [[Antibiotic resistance| super bugs]] that are now resistant to common antibiotics according to [http://www.cdc.gov/std/Gonorrhea/arg/default.htm CDC].
*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)


Antibiotics that may be used to treat gonorrhea include:
*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
* [[Amoxycillin]] 2 g plus [[probenecid]] 1 g orally
*[[Chlamydial]] co-infection:
* [[Ampicillin]] 2 to 3 g plus [[probenecid]] 1 g orally
**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
* [[Azithromycin]] 2 g orally
|-
* [[Cefixime]] 400 mg orally
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
* [[Cefotaxime]] 500 mg by intramuscular injection
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Cefoxitin]] 2 g by intramuscular injection, plus [[probenecid]] 1 g orally
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g PO as a single dose OR
* [[Cefpodoxime]] (Vantin) 400 mg orally
* [[Ceftriaxone]] (Rocephin) 125 to 250 mg by intramuscular injection
* [[Ciprofloxacin]] 500 mg orally
* [[Levofloxacin]] 250 mg orally
* [[Ofloxacin]] 400 mg orally
* [[Spectinomycin]] 2 g by intramuscular injection
These drugs are all given as a single dose.


The level of [[tetracycline]] resistance in ''Neisseria gonorrheae'' is now so high as to make it completely ineffective in most parts of the world.
*[[Cefixime]] 800 mg PO as a single dose.


The fluoroquinolones ([[ciprofloxacin]], [[ofloxacin]], [[levofloxacin]]) cannot be used in [[pregnancy]]. It is important to refer all sexual partners to be checked for gonorrhea to prevent spread of the disease and to prevent the patient from becoming re-infected with gonorrhea. Patients should also be offered screening for other sexually transmitted infections. In areas where co-infection with [[chlamydia]] is common, doctors may prescribe a combination of antibiotics, such as [[ceftriaxone]] with [[doxycycline]] or [[azithromycin]], to treat both diseases.
(Add [[doxycycline]] 100 mg PO BID for 7 days if [[Chlamydia infection|chlamydial]] infection has not been excluded)


Penicillin is ineffective at treating rectal gonorrhea: this is because other bacteria within the rectum produce β-lactamases that destroy penicillin. All current treatments are less effective at treating gonorrhea of the throat, so the patient must be rechecked by throat swab 72 hours or more after being given treatment, and then retreated if the throat swab is still positive.
(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia).
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] is not available:
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg PO OD if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h  for 7 days
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days
|}


Although gonorrhea usually does not require follow-up (with the exception of rectal or pharyngeal disease), patients are usually advised to phone for results five to seven days after diagnosis to confirm that the antibiotic they received was likely to be effective.  Patients are advised to abstain from sex during this time.
===Antimicrobial Regimen===


Drug resistant strains are known to exist.
:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 &#124; MMWR |format= |work= |accessdate=}}</ref><ref name="urlGonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm |title=Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
::*1. '''Gonococcal infections in adolescents and adults'''
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
::::*[[Chlamydial]] co-infection:
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
:::::*1.2.1 '''Management of sex partners'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296  }}</ref>
::::::*Note (1):  expedited partner therapy is not routinely recommended for men who have sex with men.
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
:::::*1.2.2  '''Allergy, intolerance, and adverse reactions'''
::::::*[[Ceftriaxone]] is not available:
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other  injectable [[cephalosporin]] not available.
::::::*Severe Cephalosporin allergy:
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.3 '''Pregnancy'''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline. <br />
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO  single dose  {{and}} [[Azithromycin]] 2 g PO  single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM  single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
:::*1.3 '''Gonococcal conjunctivitis'''
::::*Preferred regimen:  a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::::*1.3.1 '''Management of sex partners'''
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
:::*1.4 '''Disseminated gonococcal infection'''
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h  for 7 days.
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296  }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }}</ref>
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::*Preferred regimen: [[Ceftriaxone]]  25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
::::*Recommended Regimen for prevention  '''Erythromycin''' '''0.5% ophthalmic ointment''' in each eye in a single application at birth
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV  q12h for 7 days.
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: '''[[Ceftriaxone]]''' 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 500 mg IM in a single dose.
::::*Alternative regimen:  '''[[Gentamicin]]''' 240 mg IM in a single dose  PLUS  '''[[Azithromycin]]''' 2 g PO in a single dose  OR  '''[[Cefixime]]''' 800 mg PO in a single dose
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM or IV q24h for 7 days.


===United States recommendations===
===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>


The United States does not have a federal system of sexual health clinics, and the majority of infections are treated in family practices. A third-generation [[cephalosporin]] antibiotic such as ceftriaxone is recommended for use in most areas.  Since some areas such as Hawaii and California have very high levels of resistance to [[fluoroquinolone]] antibiotics (ciprofloxacin, ofloxacin, [[levofloxacin]]) they are no longer used empirically to treat infections originating in these areas.
*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or 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 patients next present for medical care within 12 months following initial treatment


===United Kingdom recommendations===
==References==
 
{{Reflist|2}}
In the United Kingdom, the majority of patients with gonorrhea are treated in dedicated sexual health clinics. The current recommendation is for ceftriaxone or cefixime as first line therapy; no resistance to either drug has yet been reported in the UK.  Levels of spectinomycin resistance in the UK are less than 1%, which would make it a good choice in theory, but intramuscular spectinomycin injection is very painful.
 
[[Azithromycin]] (given as a single dose of 2 g) is recommended if there is concurrent infection with chlamydia. A single dose of oral ciprofloxacin 500 mg is effective if the organism is known to be sensitive, but fluoroquinolones were removed from the UK recommendations for empirical therapy in 2003 because of increasing resistance rates.  In 2005, resistance rates for ciprofloxacin were 22% for the whole of the UK (42% for London, 10% for the rest of the UK).<ref>{{cite web | author=Health Protection Agency | title=The gonococcal resistance to antimicrobials surveillance programme: Annual report 2005 | url=http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/sti-gonorrhea/publications/GRASP_2005_Annual_Report.pdf  | accessdate=2006-10-28}}</ref>
 
===Historical Perspective of Treatment===


Historically it has been suggested that [[Mercury (element)|mercury]] was used as a treatment for gonorrhea.  Surgeons tools on board the recovered English warship the ''Mary Rose'' included a [[syringe]] that, according to some, was used to inject the mercury via the [[urinary meatus]] into any unfortunate crewman suffering from gonorrhea. [[Silver nitrate]] was one of the widely used drugs in the 19th century, but it became replaced by Protargol. [[Arthur Eichengrün]] invented this type of collodial silver which was marketed by [[Bayer]] from 1897 on. The silver based treatment was used until the first antibiotics came in use in the 1940's. <ref>{{cite journal
| author= Max Bender
| title = Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol)
| journal = Archives of Dermatological Research
| year = 1898
| volume = 43
| issue = 1
| pages = 31-36
| doi = 10.1007/BF01986890}}</ref>


==References==
{{WH}}
{{Reflist|2}}
{{WS}}


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Latest revision as of 23:50, 2 September 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2] Nuha Al-Howthi, MD[3]

Overview

The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, Ceftriaxone is standard of care for treatment of gonorrhea. Routinely combining ceftriaxone with azithromycin for treatment of gonorrhea is no longer recommended.

Medical Therapy

Type of gonococcal infection Regimen
Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
Uncomplicated Alternative regimen

(Add doxycycline 100 mg PO BID for 7 days if chlamydial infection has not been excluded)

(During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia).

Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available
Arthritis and arthritis-dermatitis syndrome
Gonococcal meningitis and endocarditis

Antimicrobial Regimen

  • 1. Gonococcal infections in adolescents and adults
  • 1.1 Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.
  • 1.2 Uncomplicated gonococcal infections of the pharynx
  • pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
  • ceftriaxone 1 g IM, for persons weighing ≥150 kg (300 lb).
  • Chlamydial co-infection:
    • add doxycycline 100 mg PO BID 7 days. (In pregnancy azithromycin 1 g as a single dose)
    • No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
  • 1.2.1 Management of sex partners
  • Expedited partner therapy: oral cefixime 800 mg orally once plus treatment for chlamydia is used for treatment of the partner.[5]
  • Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
  • Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
  • Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
  • Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
  • 1.2.2 Allergy, intolerance, and adverse reactions
  • 1.2.3 Pregnancy
    • Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
    • Chlamydia coinfection should be treated with azithromycin instead of doxycycline.
  • 1.2.4 Suspected cephalosporin treatment failure
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with Cefixime and Azithromycin)
  • Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
  • 1.3 Gonococcal conjunctivitis
Note: A topical fluoroquinolone, saline irrigation are also recommended.
  • 1.3.1 Management of sex partners
  • Patients should be instructed to refer their sex partners for evaluation and treatment.
  • 1.4 Disseminated gonococcal infection
  • 1.4.1 Arthritis and arthritis-dermatitis syndrome
  • Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days.
  • Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
  • Alternative regimen (2): Ceftizoxime 1 g IV q8h for 7 days.
  • Note: Once clinical improvement with ceftriaxone is noted for 24 to 48 hours, the regimen can be completed with intramuscular ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
  • 1.4.2 Gonococcal meningitis and endocarditis
  • Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days
  • 2. Gonococcal infections among neonates[6][7]
  • 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
  • Recommended Regimen for prevention Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth
  • 2.1.1 Management of mothers and their sex partners
  • Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates
  • Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV q24h for 7 days
  • Preferred regimen (2): Cefotaxime 25 mg/kg IM/IV q12h for 7 days.
  • Note (1): The duration of treatment is 10-14 days if meningitis is documented.
  • Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
  • 2.2.1 Management of mothers and their sex partners
  • Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.3 Neonates born to mothers who have gonococcal infection
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)
  • 2.3.1 Management of mothers and their sex partners
  • Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
  • 3. Gonococcal infections among infants and children
  • 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)
  • 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)
  • 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 1 g IM or IV q24h for 7 days.

Follow-Up

A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or NAAT. If the NAAT is positive, effort should be made to perform a confirmatory culture before commencing retreatment.[8]

  • All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing
  • Men or 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 patients next present for medical care within 12 months following initial treatment

References

  1. ↑ "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR".
  2. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  3. ↑ "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR".
  4. ↑ "Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines".
  5. ↑ St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K; et al. (2020). "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020". MMWR Morb Mortal Wkly Rep. 69 (50): 1911–1916. doi:10.15585/mmwr.mm6950a6. PMC 7745960 Check |pmc= value (help). PMID 33332296 Check |pmid= value (help).
  6. ↑ St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K; et al. (2020). "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020". MMWR Morb Mortal Wkly Rep. 69 (50): 1911–1916. doi:10.15585/mmwr.mm6950a6. PMC 7745960 Check |pmc= value (help). PMID 33332296 Check |pmid= value (help).
  7. ↑ Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMC 5885289. PMID 26042815.
  8. ↑ Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016


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