eMedicine Specialties > Infectious Diseases > Sexually Transmitted Diseases

Gonococcal Infections: Follow-up

Author: Brian Wong, MD, Assistant Professor of Medicine, Division of Infectious Diseases, Loma Linda University Medical Center
Coauthor(s): Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus; Renuka Heddurshetti, MD, Fellow in Infectious Diseases, Department of Internal Medicine, State University of New York at Brooklyn; Sanda Cebular, MD, Fellow, Department of Medicine, Section of Infectious Diseases, State University of New York at Brooklyn
Contributor Information and Disclosures

Updated: Apr 21, 2009

Follow-up

Further Inpatient Care

  • Hospitalization is recommended for initial treatment of disseminated gonococcal infection (DGI), purulent joint infections, meningitis, and endocarditis.
  • Hospitalization is recommended for the initial treatment of PID cases in the presence of the following factors:
    • Pregnancy
    • Failure of outpatient treatment
    • Tuboovarian abscess
    • Severe symptoms (eg, severe pain, high fever, persistent nausea and vomiting)
    • Immunodeficiency
    • Abdominal peritonitis or perihepatitis
    • Uncertain diagnosis, with any possibility of ectopic pregnancy or appendicitis masquerading as PID

Further Outpatient Care

  • Patients with DGI or PID who are treated in an outpatient setting must receive follow-up care within 24 hours.
  • Early follow-up care and culture with antibiotic sensitivities are indicated in patients with unresolved or recurrent symptoms despite therapy.
  • Immediate test of cure is not recommended by the CDC in any patient with uncomplicated gonorrhea treated with recommended or alternative treatments. It may be prudent to evaluate efficacy of therapy in all patients with pharyngitis treated with spectinomycin because of efficacy rates less than 60%.
  • Re-evaluation 3 months after treatment is recommended by the CDC. This is distinct and different from immediate test of cure.
  • Instruct patients with uncomplicated gonococcal infections to follow up with a primary care physician or public health provider to reduce the risk of future infection.

Deterrence/Prevention

  • The prevention of gonococcal infections is based on education, mechanical or chemical prophylaxis, and early diagnosis and treatment. Condoms offer partial protection. The U.S. Preventive Services Task Force (2008) recently found that behavioral counseling interventions in multiple sessions conducted in STD clinics and primary care settings effectively reduces the occurrence of STDs in at-risk adults and adolescents. However, they determined that additional studies are needed for both lower-intensity behavioral counseling interventions and the effectiveness of this technique in lower-risk patient populations.18
  • Several studies have shown that male circumcision status had no statistically significant impact on susceptibility to or acquisition of gonorrhea.19
  • All sexual contacts should be notified and treated.
  • Effective antibiotics taken in therapeutic doses immediately before or soon after exposure can mediate an infection.
  • Preventive measures also include attention to partner notification. Patients should be encouraged to notify their sexual partners of their exposure and encourage them to seek medical care. This is patient referral. If patients are unwilling or unable to notify their partners, then the assistance of state and local departments of public health can be enlisted. This is provider referral.
  • All infants born to mothers with untreated gonococcal infection should be treated prophylactically with a single dose of ceftriaxone (25-50 mg/kg IV/IM, not to exceed 125 mg).
  • All neonates should undergo prophylaxis for ophthalmia neonatorum with silver nitrate (1%) aqueous solution in both eyes once or erythromycin (0.5%) ophthalmic ointment in both eyes once.
  • Several factors, including the lack of an animal model and the diverse antigenic variability of gonorrhea, have made creation of a gonococcal vaccine difficult. Based on rabbit studies, a pilin target was the most likely vaccine candidate. Early tests in military recruits and in volunteers met with some success, but protection was strain-limited, once again because of high antigenic variation of pili. A vaccine toward porins was also evaluated, but induced anti-porin antibodies were not bactericidal.

Complications

  • Males
    • Urethral strictures secondary to gonococcal infection in men are less common than previously thought. Some strictures in the preantibiotic era likely resulted from treatment by urethral irrigation using caustic compounds rather than from the gonorrhea itself.
    • Other complications, such as penile lymphangitis, periurethral abscess, acute prostatitis, seminal vesiculitis, and infection of the Tyson and Cowper glands, are now rare.
  • Females
    • Tubal scarring and infertility are the major complications of gonococcal infection in females. The incidence of involuntary infertility is estimated at 15% after one attack of PID and approximately 50%-80% after 3 attacks.
    • The incidence of ectopic pregnancy is increased from 7-fold to 10-fold in women with previous salpingitis, with resultant increased fetal and maternal mortality rates.
    • Failure to diagnose PID can result in acute morbidity, including tuboovarian abscess, endometritis, Fitz-Hugh-Curtis syndrome (perihepatitis), and other chronic sequelae.
    • Infertility may be more common after chlamydial PID than after gonococcal PID, presumably because the more acute inflammatory signs associated with gonorrhea prompt women to seek diagnosis and treatment sooner.
  • Corneal scarring after ocular gonococcal infections
  • Destruction of joint articular surfaces in gonococcal septic arthritis
  • Destruction of cardiac valves in gonococcal endocarditis
  • Death of congestive heart failure related to endocarditis
  • CNS complications of gonococcal meningitis

Prognosis

  • With adequate early therapy, complete cure and return to normal function are the rule.
  • Late, delayed, or inappropriate therapy may lead to significant morbidity or, on rare occasions, death.

Patient Education

  • Discuss STDs and methods of prevention.
  • Discuss HIV infection and risks; encourage patients and their partner(s) to be tested.
  • Patients should avoid sexual contact until medical therapy is completed and until their partners are fully evaluated and treated. They should avoid unprotected contact thereafter.
  • For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases and Gonorrhea.

Miscellaneous

Medicolegal Pitfalls

  • Failure to treat coinfection with chlamydia (High rates of coinfection with chlamydial organisms are well documented.)
  • Failure to diagnose surgical emergencies (eg, ectopic pregnancy, appendicitis) in patients with a clinical diagnosis of PID
  • Failure to evaluate culture results to confirm the clinical diagnosis in cases with associated legal issues
  • Failure to recognize quinolone resistance (high in some countries)
 


More on Gonococcal Infections

Overview: Gonococcal Infections
Differential Diagnoses & Workup: Gonococcal Infections
Treatment & Medication: Gonococcal Infections
Follow-up: Gonococcal Infections
Multimedia: Gonococcal Infections
References
Further Reading
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References

  1. Ilina EN, Vereshchagin VA, Borovskaya AD, Malakhova MV, Sidorenko SV, Al-Khafaji NC, et al. Relation between genetic markers of drug resistance and susceptibility profile of clinical Neisseria gonorrhoeae strains. Antimicrob Agents Chemother. Jun 2008;52(6):2175-82. [Medline].

  2. Palmer HM, Young H, Graham C, Dave J. Prediction of antibiotic resistance using Neisseria gonorrhoeae multi-antigen sequence typing. Sex Transm Infect. Aug 2008;84(4):280-4. [Medline].

  3. Kerle KK, Mascola JR, Miller TA. Disseminated gonococcal infection. Am Fam Physician. Jan 1992;45(1):209-14. [Medline].

  4. Department of Health and Human Services, Centers for Disease Control and Prevention. STD Surveillance 2006: National Profile, Gonorrhea. Available at http://www.cdc.gov/std/stats/gonorrhea.htm.

  5. Da Ros CT, Schmitt Cda S. Global epidemiology of sexually transmitted diseases. Asian J Androl. Jan 2008;10(1):110-4. [Medline].

  6. AVERT.org. STD Statistics Worldwide. Available at http://www.avert.org/stdstatisticsworldwide.htm.

  7. Department of Health and Human Services, Centers for Disease Control and Prevention. STD Surveillance 2006: Trends in Reportable Sexually Transmitted Diseases in the United States, National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis. Available at http://www.cdc.gov/std/stats/trends2006.htm.

  8. Holder NA. Gonococcal infections. Pediatr Rev. Jul 2008;29(7):228-34. [Medline].

  9. Schachter J, Hook EW 3rd, McCormack WM, Quinn TC, Chernesky M, Chong S, et al. Ability of the digene hybrid capture II test to identify Chlamydia trachomatis and Neisseria gonorrhoeae in cervical specimens. J Clin Microbiol. Nov 1999;37(11):3668-71. [Medline].

  10. Hjelmevoll SO, Olsen ME, Sollid JU, Haaheim H, Melby KK, Moi H, et al. Clinical validation of a real-time polymerase chain reaction detection of Neisseria gonorrheae porA pseudogene versus culture techniques. Sex Transm Dis. May 2008;35(5):517-20. [Medline].

  11. Whiley DM, Garland SM, Harnett G, Lum G, Smith DW, Tabrizi SN, et al. Exploring 'best practice' for nucleic acid detection of Neisseria gonorrhoeae. Sex Health. Mar 2008;5(1):17-23. [Medline].

  12. McNally LP, Templeton DJ, Jin F, Grulich AE, Donovan B, Whiley DM, et al. Low positive predictive value of a nucleic acid amplification test for nongenital Neisseria gonorrhoeae infection in homosexual men. Clin Infect Dis. Jul 15 2008;47(2):e25-7. [Medline].

  13. Alary M, Gbenafa-Agossa C, Aïna G, Ndour M, Labbé AC, Fortin D, et al. Evaluation of a rapid point-of-care test for the detection of gonococcal infection among female sex workers in Benin. Sex Transm Infect. Dec 2006;82 Suppl 5:v29-32. [Medline].

  14. Greer L, Wendel GD Jr. Rapid diagnostic methods in sexually transmitted infections. Infect Dis Clin North Am. Dec 2008;22(4):601-17, v. [Medline].

  15. CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].

  16. 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]. [Full Text].

  17. Morrow GL, Abbott RL. Conjunctivitis. Am Fam Physician. Feb 15 1998;57(4):735-46. [Medline].

  18. [Best Evidence] Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral counseling to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. Oct 7 2008;149(7):497-508, W96-9. [Medline].

  19. Van Howe RS. Genital ulcerative disease and sexually transmitted urethritis and circumcision: a meta-analysis. Int J STD AIDS. Dec 2007;18(12):799-809. [Medline].

  20. Sparling PF. Gonococcal Infections. In: Cecil RL, Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. ed. Philadelphia, Pa: WB Saunders; 2000:1743-5.

  21. Sparling PF, Handsfield HH. Neisseria gonorrhoeae. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:2242-58.

  22. World Health Organization. Initiative for Vaccine Research (IVR). Available at http://www.who.int/vaccine_research/diseases/soa_std/en/index2.html.

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Further Reading

The body of this article is derived from the following references:

  • Sparling PF. Gonococcal Infections. In: Cecil RL, Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 1st ed. Philadelphia, Pa: WB Saunders; 2000:1743-5.
  • Sparling PF, Handsfield HH. Neisseria gonorrhoeae. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:2242-58.

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Keywords

gonorrhea, gonococcal infection, Neisseria gonorrhoeae, N gonorrhoeae, sexually transmitted disease, STD, the clap, gonorrheal infection, ophthalmia neonatorum, endocervicitis, urethritis, pelvic inflammatory disease, PID, anterior urethritis, salpingitis, tuboovarian abscess, tubo-ovarian abscess, endometritis, Fitz-Hugh and Curtis syndrome, Fitz-Hugh-Curtis syndrome, perihepatitis, gonococcal urethritis, gonococcal pelvic inflammatory disease, gonococcal PID, gonococcemia, disseminated gonococcal infection, DGI, gonococcal cervicitis, gonococcal pharyngitis, cervical gonorrhea, gonococcal bacteremia, gonococcal arthritis, gonococcal meningitis, gonococcal endocarditis, gonococcal septic arthritis

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Contributor Information and Disclosures

Author

Brian Wong, MD, Assistant Professor of Medicine, Division of Infectious Diseases, Loma Linda University Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Renuka Heddurshetti, MD, Fellow in Infectious Diseases, Department of Internal Medicine, State University of New York at Brooklyn
Renuka Heddurshetti, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Sanda Cebular, MD, Fellow, Department of Medicine, Section of Infectious Diseases, State University of New York at Brooklyn
Sanda Cebular, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Kenneth C Earhart, MD, Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3
Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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