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===Historical Perspective of Treatment=== | ===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 | 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. | ||
===Antimicrobial Regimen=== | |||
:* '''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> | |||
::* 1. '''Gonococcal infections in adolescents and adults''' | |||
:::* 1.1 '''Uncomplicated gonococcal infections of the cervix, urethra, and rectum''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
::::* Alternative regimen: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose (if ceftriaxone is not available) | |||
:::* 1.2 '''Uncomplicated gonococcal infections of the pharynx''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
:::::* 1.2.1 '''Management of sex partners''' | |||
::::::* Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
::::::* Note (1): 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 (2): 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 (3): 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''' | |||
::::::* Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose | |||
::::::* Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose | |||
::::::* 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''' | |||
::::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
:::::* 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) persons 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) persons 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: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
::::: Note: Consider one-time lavage of the infected eye with saline solution. | |||
:::::* 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 {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
::::::* Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days | |||
::::::* Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
:::::* 1.4.2 '''Gonococcal meningitis and endocarditis''' | |||
::::::* Preferred regimen: [[Ceftriaxone]] 1-2 g IV q 12-24 h for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose | |||
::* 2. '''Gonococcal infections among neonates''' | |||
:::* 2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg | |||
:::::* 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 125 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 IM/IV in a single dose, not to exceed 125 mg | |||
:::* 3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose | |||
::::* Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available) | |||
:::* 3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days | |||
:::* 3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis''' | |||
::::* Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days | |||
<ref>{{cite journal | |||
| author= Max Bender | | author= Max Bender | ||
| title = Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol) | | title = Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol) | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Medical Therapy
Acute Pharmacotherapies
-
Gonorrhea treatment advertisement from 1944, when penicillin became widely available due to mass production.
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.
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 treatment is the appropriate use of antibiotics. 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.
The Centers for Disease Control and Prevention (CDC) released a report on Thursday, April 12, 2007 officially adding gonorrhea to a list of super bugs that are now resistant to common antibiotics according to CDC.
Antibiotics that may be used to treat gonorrhea include:
- Amoxycillin 2 g plus probenecid 1 g orally
- Ampicillin 2 to 3 g plus probenecid 1 g orally
- Azithromycin 2 g orally
- Cefixime 400 mg orally
- Cefotaxime 500 mg by intramuscular injection
- Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally
- 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.
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.
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.
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.
Drug resistant strains are known to exist.
United States recommendations
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.
United Kingdom recommendations
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).[1]
Historical Perspective of Treatment
Historically it has been suggested that 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.
Antimicrobial Regimen
- Neisseria gonorrhoeae treatment[2]
- 1. Gonococcal infections in adolescents and adults
- 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
- Alternative regimen: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose (if ceftriaxone is not available)
- 1.2 Uncomplicated gonococcal infections of the pharynx
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
- 1.2.1 Management of sex partners
- Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
- Note (1): 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 (2): 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 (3): 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
- Preferred regimen (1): Gemifloxacin 320 mg PO in a single dose AND Azithromycin 2 g PO in a single dose
- Preferred regimen (2): Gentamicin 240 mg IM in a single dose AND Azithromycin 2 g PO in a single dose
- 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
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
- 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) persons 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) persons 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: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
- Note: Consider one-time lavage of the infected eye with saline solution.
- 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 AND Azithromycin 1 g PO in a single dose
- Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
- Alternative regimen (2): Ceftizoxime 1 g IV q8h for 7 days AND Azithromycin 1 g PO in a single dose
- 1.4.2 Gonococcal meningitis and endocarditis
- Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days AND Azithromycin 1 g PO in a single dose
- 2. Gonococcal infections among neonates
- 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae
- Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
- 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 125 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 IM/IV in a single dose, not to exceed 125 mg
- 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1g PO in a single dose
- Alternative regimen: Cefixime 400 mg PO single dose AND Azithromycin 1 g PO single dose.(If ceftriaxone is not available)
- 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis
- Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
- 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis
- Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days
[3]
References
- ↑ Health Protection Agency. "The gonococcal resistance to antimicrobials surveillance programme: Annual report 2005" (PDF). Retrieved 2006-10-28.
- ↑ 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.
- ↑ Max Bender (1898). "Ueber neuere Antigonorrhoica (insbes. Argonin und Protargol)". Archives of Dermatological Research. 43 (1): 31–36. doi:10.1007/BF01986890.