eMedicine Specialties > Ophthalmology > Infectious Disease
Gonococcus: Treatment & Medication
Updated: Nov 2, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- It is important to treat all sexual partners simultaneously to prevent reinfection.
- It is prudent to examine all sexual partners for other venereal diseases (eg, gonorrhea, syphilis).
- Treatment consists of systemic antibiotics; topical antibiotics are relatively ineffective in the treatment of eye disease.
- Since 1993, fluoroquinolones (ie, ciprofloxacin, ofloxacin, levofloxacin) have been used frequently in the treatment of gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy. However, the prevalence of fluoroquinolone resistance in N gonorrhoeae has been increasing and is becoming widespread in the United States, thereby necessitating changes in treatment regimens.
- Beginning in 2000, fluoroquinolones were no longer recommended for the treatment of persons with gonorrhea who acquired their infections in Asia or the PacificIslands (including Hawaii); in 2002, this recommendation was extended to California.
- In 2004, the Centers for Disease Control and Prevention (CDC) recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM). This report, based on data from the Gonococcal Isolate Surveillance Project (GISP), summarizes data on fluoroquinolone-resistant N gonorrhoeae (QRNG) in heterosexual males and in MSM throughout the United States. This report also updates the CDC's Sexually Transmitted Diseases Treatment Guidelines (2006) regarding the treatment of infections caused by N gonorrhoeae. On the basis of the most recent evidence, the CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions (eg, PID).
- Consequently, only one class of drugs, cephalosporins, is still recommended and available for the treatment of gonorrhea.1
- Current recommended treatment is ceftriaxone 125 mg intramuscularly in a single dose or cefixime 400 mg orally in a single dose or 400 mg by suspension (200 mg/5 mL). Spectinomycin (2 g IM) can be given to patients who are allergic to penicillin; however, it is not currently available in the United States.2
- Concurrent treatment of chlamydia should be given for 3-6 weeks, to include oral tetracycline 500 mg 4 times a day, oral doxycycline 100 mg twice a day, or oral erythromycin stearate 500 mg 4 times a day. Azithromycin can be given as a single 1-g dose.
- If the eye is involved beyond the conjunctiva (ie, cornea, vitreous), then dosages are similar to those of disseminated infection, and topical antibiotics are added. See Endophthalmitis, Bacterial.
- If the cornea is involved or if corneal involvement cannot be excluded due to lid swelling or chemosis, some physicians treat with a 3-day course of intravenous antibiotics (eg, ceftriaxone 1 g IV q12-24h).
Medication
Treatment of N gonorrhoeae and Chlamydia trachomatis is generally indicated for lower genitourinary infections, PID, epididymitis, proctitis, pharyngitis, conjunctivitis, and DGI. Antibiotics for coverage of gonococcal infection are listed below. Additional regimens are available but show no clear advantage over the antibiotics. Chlamydial infection or suspected infection is covered by azithromycin or doxycycline. Erythromycin and amoxicillin are less effective but should be substituted in pregnant women and children. Treatment of PID may require coverage for additional organisms, including enteric anaerobes.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Bactericidal activity results from inhibition of cell wall synthesis. Has high degree of stability in presence of beta-lactamases, both penicillinases and cephalosporinases, of gram-negative and gram-positive bacteria.
Adult
Urethral, endocervical, rectal, pharyngeal, or conjunctivitis: 125 mg IM once
Deep ophthalmic or disseminated (arthritis, meningitis): 2 g/d IV/IM
Pediatric
Urethral, endocervical, rectal, pharyngeal, or conjunctivitis: Administer as in adults
Deep ophthalmic or disseminated (arthritis, meningitis): 50-100 mg/kg/d IV/IM
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Although transient elevations of BUN and serum creatinine have been observed, at recommended dosages, nephrotoxic potential is similar to that of other cephalosporins; in hepatic dysfunction and significant renal disease, dosage should not exceed 2 g qd if not monitoring closely; alterations in prothrombin times may occur; in impaired vitamin K synthesis or low vitamin K stores (eg, chronic hepatic disease, malnutrition) monitoring of prothrombin time may be required; vitamin K administration (10 mg weekly) may be necessary if prothrombin time is prolonged before or during therapy
Prolonged use may result in overgrowth of nonsusceptible organisms; caution in individuals with history of gastrointestinal disease, especially colitis; sonographic abnormalities in gallbladder of patients treated with Rocephin may occur; chemical nature of sonographically detected material has been determined to be predominantly a ceftriaxone-calcium salt (condition appears to be transient and reversible upon discontinuation of medication and institution of conservative management)
Discontinue treatment if symptoms suggestive of gallbladder disease and/or the sonographic findings described above develop
Azithromycin (Zithromax)
Treats mild-to-moderate microbial infections.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Pediatric
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100-200 mg/d PO qd or divided bid for 10-14 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d qd or divided bid; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Erythromycin (EES, E-Mycin, Ery-Tab)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h, or 500 mg q12h (1 h ac or 2 pc)
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Amoxicillin (Amoxil, Polymox, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.
Adult
250-500 mg PO q8h; not to exceed 3 g/d
Pediatric
20-50 mg/kg/d PO divided q8h
Reduces the efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Spectinomycin (Trobicin)
Used to treat most types of gonorrhea. Given by injection into a muscle. Sometimes given with other medicines for gonorrhea and related infections.
May be used in patients who are allergic to penicillins, cephalosporins, or probenecid (eg, Benemid). This medicine also is used to treat recent sexual partners of patients who have gonorrhea.
Second-line treatment of gonorrhea and gonococcal urethritis, cervicitis, or proctitis in patients who are infected with penicillin-resistant strains of N gonorrhoeae. Treatment of gonorrhea and gonococcal urethritis, cervicitis, or proctitis in patients allergic to beta-lactam anti-infectives (including ceftriaxone).
Inhibits bacterial protein synthesis at the level of the 30S ribosome. Bactericidal action against susceptible organisms. Most notable for activity against N gonorrhoeae, including penicillinase-producing strains (PPNG). Not active against Treponema pallidum or C trachomatis.
Adult
Adults and children 45 kg (99 lb) and over: 2 g IM single dose
Pediatric
Infants: Not recommended
Children up to 45 kg (99 lb): 40 mg/kg of body weight IM single dose
None reported
Documented hypersensitivity; neonates (diluent contains benzyl alcohol)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Concurrent infection with other STD (additional anti-infectives may be required); pregnancy, breastfeeding, or children (safety not established; has been used)
Tetracycline (Sumycin)
Treats gram-positive and gram-negative organisms, as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).
Adult
500 mg PO qid
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Cefixime (Suprax)
Third-generation oral cephalosporin with broad activity against gram-negative bacteria. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Note: After a period of inavailability, oral cefixime is again FDA-approved in tablet and suspension forms. However, at the time of writing, tablets remain unavailable in the United States. Wyeth Pharmaceuticals (Collegeville, Pa) discontinued manufacturing cefixime (Suprax) in the United States. In October 2002, the company ceased marketing cefixime tablets (200 mg and 400 mg) because of depletion of company inventory; the company's patent for cefixime expired on November 10, 2002.
Adult
400 mg/d PO (recommended for gonococcal infections) or 200 mg PO q12h
Pediatric
<12 years: 8 mg/kg/d suspension PO or 4 mg/kg bid
>50 kg or >12 years: Administer as in adults
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
More on Gonococcus |
| Overview: Gonococcus |
| Differential Diagnoses & Workup: Gonococcus |
 Treatment & Medication: Gonococcus |
| Follow-up: Gonococcus |
| References |
| « Previous Page | Next Page » |
References
Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline].
Centers for Disease Control and Prevention (CDC). Updated recommended treatment regimens for gonococcal infections and associated conditions - United States, April 2007. CDC. Available at http://www.cdc.gov/std/treatment/2006/updated-regimens.htm. Accessed July 17, 2007.
Harkins T. Sexually transmitted diseases. Optom Clin. 1994;3(4):129-56. [Medline].
Isenberg SJ, Apt L, Campeas D. Ocular applications of povidone-iodine. Dermatology. 2002;204 Suppl 1:92-5. [Medline].
Kestelyn P, Bogaerts J, Meheus A. Gonorrheal keratoconjunctivitis in African adults. Sex Transm Dis. Oct-Dec 1987;14(4):191-4. [Medline].
Lee JS, Choi HY, Lee JE, Lee SH, Oum BS. Gonococcal keratoconjunctivitis in adults. Eye. Sep 2002;16(5):646-9. [Medline].
Reed K, Jones MW. PPNG conjunctivitis. J Am Optom Assoc. Jun 1984;55(6):425-7. [Medline].
Schwab L, Tizazu T. Destructive epidemic Neisseria gonorrheae keratoconjunctivitis in African adults. Br J Ophthalmol. Jul 1985;69(7):525-8. [Medline].
Tight RR. Gonococcal conjunctivitis. JAMA. May 14 1982;247(18):2499. [Medline].
Ullman S, Roussel TJ, Culbertson WW, Forster RK, Alfonso E, Mendelsohn AD, et al. Neisseria gonorrhoeae keratoconjunctivitis. Ophthalmology. May 1987;94(5):525-31. [Medline].
Ullman S, Roussel TJ, Forster RK. Gonococcal keratoconjunctivitis. Surv Ophthalmol. Nov-Dec 1987;32(3):199-208. [Medline].
Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. Am J Ophthalmol. Nov 15 1986;102(5):575-83. [Medline].
Zajdowicz TR, Kerbs SB, Berg SW, Harrison WO. Laboratory-acquired gonococcal conjunctivitis: successful treatment with single-dose ceftriaxone. Sex Transm Dis. Jan-Mar 1984;11(1):28-9. [Medline].
Further Reading
Keywords
gonorrhea, Neisseria gonorrhoeae, N gonorrhoeae, hyperacute conjunctivitis, sexually transmitted disease, STD
