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Gonorrhea Treatment & Management

  • Author: Brian Wong, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Mar 15, 2016
 

Approach Considerations

As discussed in the Workup section, females with diagnosed or suspected sexually transmitted diseases (STDs) should have a concomitant pregnancy test. This guides further care and allows treatment with medications that are not approved for use in pregnancy.

Identification and treatment of the patient's partner and any partners of the partner are important to prevent reinfection and complications.

Prevention of neonatal disease is with the use of silver nitrate, erythromycin, ciprofloxacin, gentamicin, or erythromycin eye drops.

Inpatient versus outpatient treatment

The main decision once a diagnosis of gonorrhea has been made, either definitively or presumptively, is whether to treat the patient as an outpatient or to hospitalize him or her.

For males, treatment is always outpatient for genital infection; however, admission may be necessary for complications such as disseminated gonococcal infection (DGI) or gonococcal arthritis.

In females, the decision is much more difficult, because the risk of complications is much higher. In light of high rates of noncompliance, reinfection, and poor follow-up, some clinicians advocate admitting a female patient whenever a question of a complication such as pelvic inflammatory disease (PID) is present, particularly in the adolescent population.

Many institutions have attempted to quantify abnormalities found on pelvic examination (ie, the PID score) in an attempt to admit those patients with a higher likelihood of complications.

In cases in which future fertility is at risk, most physicians are fairly aggressive, especially in situations in which the patient is very young or unfamiliar to them.

Many physicians admit patients who have corneal involvement for treatment with IV antibiotics. These patients can be discharged once the infection is under control and the corneal infection is improving.

Surgical care

Septic joints should be aspirated to make the initial diagnosis and to remove inflammatory exudate. Open drainage is rarely indicated, except in infections of the hip in children. Most authorities recommend removal of intrauterine devices in women with PID.

Activity

Patients with uncomplicated gonococcal disease can remain fully active.

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Pharmacologic Treatment Regimens

Because of resistance with oral cephalosporins, only 1 regimen, dual treatment with ceftriaxone and azithromycin, is recommended for treatment of gonorrhea in the United States. Dual therapy with ceftriaxone and azithromycin should be administered together on the same day, preferably simultaneously and under direct observation. In addition, persons infected with N gonorrhoeae frequently are coinfected with C trachomatis; this finding has led to the longstanding recommendation that persons treated for gonococcal infection also be treated with a regimen that is effective against uncomplicated genital C trachomatis infection, further supporting the use of dual therapy that includes azithromycin.[1]

Uncomplicated urogenital, anorectal, and pharyngeal gonococcal infection

First-line dual drug therapy regimen is as follows[1] :

  • Ceftriaxone 250 mg intramuscular (IM) single dose PLUS,
  • Azithromycin 1 g PO single dose

The 250-mg IM dose of ceftriaxone is now recommended over the 125-mg dose, given concern for resistance, prior lower-dose ceftriaxone dose failures, and seemingly improved efficacy in pharyngeal infections. Ceftriaxone is safe and effective in pregnant women and probably destroys incubating syphilis. Its major drawback is the necessity for IM administration.

A review of the recommendations for antimicrobial treatment of uncomplicated gonorrhea in 11 East European countries showed ceftriaxone (250-1000 mg IM once) was a first-line antimicrobial in all of them.[43] (However, many of the second-line and alternative treatments were less than ideal, with regionally manufactured antimicrobials predominantly used.)

Data has indicated that the 400-mg oral dose of cefixime does not provide a bactericidal level that is as high or as sustained as that of the 250-mg dose of ceftriaxone. In addition, based on findings from the Gonococcal Isolate Surveillance Project (GISP), reported July 2011, from 2009-2010 a decreasing susceptibility to cefixime was found.[44] In response, the CDC issued revised guidelines that do not include oral cephalosporins as first-line treatment.[45]

Because of the persistent increase in multidrug-resistant gonorrhea, the 2015 CDC treatment recommendations are as follows[1] :

  • Treat gonorrhea at any anatomic site with a single intramuscular injection of 250 mg ceftriaxone plus azithromycin 1 g PO as a single dose
  • If ceftriaxone is unavailable, patients can be given a single oral dose of cefixime 400 mg plus a single dose of azithromycin 1 g PO

Alternative treatment options

If cephalosporin allergic, consider alternant dual therapy with single doses of gemifloxacin PO 320 mg plus azithromycin 2 g PO, or gentamicin 240 mg IM plus azithromycin 2 g PO.

Another alternative regimen for patients intolerant of cephalosporins include is spectinomycin (2 g IM). Spectinomycin may be costly and is currently unavailable in the United States.

If azithromycin allergic, doxycycline (100 mg PO BID for 7 days) can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime.

Patients should return for a test of cure in 1 week. The CDC advises that clinicians should perform susceptibility testing in patients who fail to respond to treatment and notify their local public health STD program.[46]

Monotherapy with azithromycin is no longer recommended because of concerns over the ease with which N gonorrhoeae can develop resistance to macrolides, and because several studies have documented azithromycin treatment failures. Strains of N gonorrhoeae circulating in the United States are not adequately susceptible to penicillins, tetracyclines, or older macrolides (eg, erythromycin); thus, use of these antimicrobials cannot be recommended.[1]

Gonococcal pharyngeal infections may be more challenging to eradicate than infections involving urogenital and anorectal areas.[47]

Investigational and future treatment options

In a clinical trial conducted by the CDC and NIH, 2 new antibiotic regimens successfully treated gonorrhea infections. The 2 regimens consist of gentamicin IV plus azithromycin PO, and gemifloxacin PO plus azithromycin PO. The study was conducted to identify new treatment options in the face of growing antibiotic resistance.[48, 49] While the study results offer successful treatment options, the CDC is not recommending a change in current guidelines due to the severe gastrointestinal side effects reported by trial participants. However, providers may consider using the regimens studied in this trial as alternative options when ceftriaxone cannot be used.[50]

The study of these antibiotic regimens included 401 men and women ranging in age from 15 years to 60 years. The combination treatments were highly effective in curing genital gonorrhea infections. The gentamicin plus azithromycin was found to be 100% effective and the gemifloxacin plus azithromycin was 99.5% effective. Both combinations cured 100% of gonococcal infections of the throat and rectum.[48, 49]

Although highly effective, the regimens frequently caused adverse GI effects. Of the 202 participants in the gentamicin plus azithromycin arm, 28% experienced nausea, 19% experienced diarrhea, and 7% experienced either abdominal discomfort/pain or vomiting. Of the 199 participants in the gemifloxacin plus azithromycin arm, 37% experienced nausea, 23% experienced diarrhea, and 11% experienced abdominal discomfort/pain.[48, 49]

Drugs that are no longer recommended

Prior to 2007, fluoroquinolones were the preferred class of antimicrobials for the treatment of gonorrhea; however, reports surfaced of N gonorrhoeae infection with decreasing susceptibilities and frank resistance. In addition, United States gonococcal strains with elevated MICs to cefixime also are likely to be resistant to tetracyclines but susceptible to azithromycin. Consequently, only 1 regimen, dual treatment with ceftriaxone and azithromycin, is recommended for treatment of gonorrhea in the United States.[1]

In August 2012, the CDC announced changes to 2010 sexually transmitted disease guidelines for gonorrhea treatment. The Gonococcal Isolate Surveillance Project (GISP) described a decline in cefixime susceptibility among urethral N gonorrhoeae isolates in the United States during 2006-2011. Because of cefixime’s susceptibility, new guidelines were issued that no longer recommend oral cephalosporins for first-line gonococcal infection treatment.[45]

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics were no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's aforementioned GISP. The data showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001.[6]

Tetracyclines are no longer acceptable first-line therapy for gonorrhea because of the prevalence of tetracycline-resistant strains. Doxycycline 100 mg PO BID for 7 days can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime (also second-line therapy). Furthermore, as cefixime becomes less effective, continued used of cefixime might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial known to be highly effective in a single dose for treatment of gonorrhea at all anatomic sites of infection. Other oral cephalosporins (eg, cefpodoxime and cefuroxime) are not recommended because of inferior efficacy and less favorable pharmacodynamics. The frequency of such gonococcal strains is increasing, having climbed to 5-15% in various US cities.[1]

Gonococcal arthritis

Recommended therapy is with ceftriaxone at 1 g daily IV/IM plus a single dose of azithromycin 1 g PO. Initial IV/IM treatment should be continued for 1-2 days after symptoms improve.

Alternative regimens include cefotaxime or ceftizoxime 1 g IV every 8 hours plus a single dose of azithromycin 1 g PO.[1]

Gonococcal conjunctivitis

Treatment recommendations for adults are single doses of ceftriaxone 1 g IM plus azithromycin 1 g PO with saline irrigation.[1, 51] Topical antibiotic solutions may also be considered. 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 IV antibiotics (eg, ceftriaxone 1 g IV q12-24h).[52]

Gonorrhea contributing to pelvic inflammatory disease

All regimens used to treat PID should also be effective against N gonorrhoeae and C trachomatis because endocervical screening that is negative for these organisms does not rule out upper-reproductive–tract infection.

The preferred regimen is a single dose of ceftriaxone 2 g IM plus doxycycline 100 mg PO BID for 14 days with or without metronidazole 500 mg PO BID for 14 days.

Other regimens are also effective and should take into consideration severity of PID and if tubo-ovarian abscess is present.[1]

Gonococcal epididymitis

Recommended therapy includes ceftriaxone 250 mg IM as a single dose with doxycycline 100 mg orally twice daily for a total of 10 days.

Disseminated gonococcal infection

The summary for this regimen is as follows:

  • Ceftriaxone 1 g IM/IV every 24 hours plus a single dose of azithromycin 1 g PO
  • Alternative regimens - Cefotaxime 1 g IV every 8 hours OR  ceftizoxime 1 g IV every 8 hours plus a single dose of azithromycin 1 g PO

Ceftriaxone IV therapy is recommended initially (for at least 24-48 h, until clinical improvement), before transitioning to IM therapy.

The combination of IV and IM cephalosporin antibiotics should be administered for a total duration of 7 days.

Gonococcal meningitis and endocarditis

Hospitalization and consultation with an infectious-disease specialist are recommended for initial therapy. See CDC STD treatment guidelines 2010 for treatment of gonococcal infection in children and the newborn.[1]

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Consultations

The following consultations should be made in cases of gonococcal infections:

  • Gynecologist - Should be consulted for patients with severe pelvic inflammatory disease (PID) and for any pregnant patient with an STD
  • Pediatrician - Should be consulted for any child with an STD
  • Ophthalmologist - Should be consulted for every patient with gonococcal conjunctivitis, as this disease may progress rapidly and can cause permanent loss of vision
  • Infectious disease specialist - May be of benefit in cases of disseminated gonococcal infection (DGI) or complicated disease courses

In cases of suspected rape or abuse in pediatric patients, seeking specialist help (in the form of specialist nurses or physicians) to interview and collect specimens (if necessary) for testing is prudent. Careful documentation of physical findings, even if apparently normal, is crucial for medicolegal reasons. Notification of child-protective services is required if abuse is suspected.

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Monitoring

Patients with disseminated gonococcal infection (DGI) or pelvic inflammatory disease (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 of less than 60%.

Reevaluation 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.

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Deterrence and Prevention

The prevention of gonococcal infections is based on education, mechanical or chemical prophylaxis, and early diagnosis and treatment. Condoms offer partial protection, while effective antibiotics taken in therapeutic doses immediately before or soon after exposure can mediate an infection. Several studies have shown that male circumcision status had no statistically significant impact on susceptibility to or acquisition of gonorrhea.[53, 54]

The US Preventive Services Task Force (2008) 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 evaluation of lower-intensity behavioral counseling interventions and behavioral counseling in lower-risk patient populations.[55]

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.

The American College of Obstetricians and Gynecologists (ACOG) has released guidelines on expedited partner therapy for chlamydial and gonorrheal sexually transmitted diseases (STDs).[56, 57] While designed to prevent reinfection with chlamydia and gonorrhea, the recommendations can also be applied to other STDs. The ACOG recommendations include the following:

  • Expedited partner therapy to prevent reinfection, with legalization of expedited partner therapy
  • Counsel partners to undergo screening for HIV infection and other STDs
  • Expedited partner therapy contraindicated in cases of suspected abuse or compromised patient safety; pretreatment evaluation for abuse potential recommended
  • Expedited partner therapy medications and protocols based on CDC, state, and/or local guidelines 

Screening

Because of the health risks from asymptomatic gonorrhea, the US Preventive Services Task Force recommends gonorrhea screening women who are at increased risk for infection, including the following[30] :

  • Patients with previous gonorrheal infection
  • Patients with other STDs
  • Patients with new or multiple sex partners
  • Patients who engage in inconsistent condom use
  • Patients who engage in commercial sex work and drug use
  • Patients living in communities with a high prevalence of disease

Because the prevalence of asymptomatic gonorrhea in men is low, evidence was insufficient for the task force to either recommend or not recommend routine screening of men at increased infection risk.

Prophylaxis in neonates

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.

Research

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.[24]

PRO-2000, an antimicrobial gel for the potential prevention of HIV infection, is in phase III trial for the prevention of sexually transmitted infections, including HIV, herpes, chlamydia, and gonorrhea, in Africa.[58]

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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.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Neal Ammar, MD Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School

Neal Ammar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and Sigma Xi

Disclosure: Nothing to disclose.

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association,Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Nicholas John Bennett, MB, BCh, PhD, Assistant Professor in Pediatrics, Division of Infectious Diseases, Connecticut Children's Medical Center

Nicholas John Bennett, MB, BCh, PhD, is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics

Disclosure: Nothing to disclose.

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.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

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.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

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.

Rajendra Kapila, MD, MBBS Associate Professor, Department of Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

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.

Jeffrey Meffert, MD Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. [Guideline] Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [Medline]. [Full Text].

  2. Dawe RS, Sweeney G, Munro CS. A vesico-pustular rash and arthralgia. Clin Exp Dermatol. 2001 Jan. 26(1):113-4. [Medline].

  3. Belding ME, Carbone J. Gonococcemia associated with adult respiratory distress syndrome. Rev Infect Dis. 1991 Nov-Dec. 13(6):1105-7. [Medline].

  4. Walters DG, Goldstein RA. Adult respiratory distress syndrome and gonococcemia. Chest. 1980 Mar. 77(3):434-6. [Medline].

  5. Thiéry G, Tankovic J, Brun-Buisson C, Blot F. Gonococcemia associated with fatal septic shock. Clin Infect Dis. 2001 Mar 1. 32(5):E92-3. [Medline].

  6. [Guideline] 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. 2007 Apr 13. 56(14):332-6. [Medline].

  7. Cucurull E, Espinoza LR. Gonococcal arthritis. Rheum Dis Clin North Am. 1998 May. 24(2):305-22. [Medline].

  8. Watring WG, Vaughn DL. Gonococcemia in pregnancy. Obstet Gynecol. 1976 Oct. 48(4):428-30. [Medline].

  9. Angulo JM, Espinoza LR. Gonococcal arthritis. Compr Ther. 1999 Mar. 25(3):155-62. [Medline].

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

  11. 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. 2008 Jun. 52(6):2175-82. [Medline].

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

  13. Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. 2006 Jan. 33(1):36-51. [Medline].

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

  15. Little JW. Gonorrhea: update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Feb. 101(2):137-43. [Medline].

  16. Centers for Disease Control and Prevention (CDC). 2010 Sexually Transmitted Diseases Surveillance: Gonorrhea. Available at http://www.cdc.gov/std/stats10/gonorrhea.htm. Accessed: May 21 2012.

  17. National Institute of Allergy and Infectious Diseases. Gonorrhea. Available at http://www.niaid.nih.gov/topics/gonorrhea/Pages/default.aspx. Accessed: August 16, 2011.

  18. Centers for Disease Control and Prevention. 2009 Sexually Transmitted Diseases Surveillance: Gonorrhea. Available at http://www.cdc.gov/STD/stats09/gonorrhea.htm. Accessed: 5/27/11.

  19. Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE Jr, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health. 2009 Jul. 45(1):8-24. [Medline].

  20. Bleich AT, Sheffield JS, Wendel GD Jr, Sigman A, Cunningham FG. Disseminated gonococcal infection in women. Obstet Gynecol. 2012 Mar. 119(3):597-602. [Medline].

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

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

  23. World Health Organization. Emergence of multi-drug resistantNeisseria gonorrhoeae –Threat of global rise in untreatable sexuallytransmitted infections. Available at http://whqlibdoc.who.int/hq/2011/WHO_RHR_11.14_eng.pdf. Accessed: August 16, 2011.

  24. World Health Organization. Initiative for Vaccine Research (IVR). Available at http://www.who.int/vaccine_research/diseases/soa_std/en/index2.html. Accessed: August 16, 2011.

  25. Goodyear-Smith F. What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forensic Leg Med. 2007 Nov. 14(8):489-502. [Medline].

  26. Martin IM, Foreman E, Hall V, Nesbitt A, Forster G, Ison CA. Non-cultural detection and molecular genotyping of Neisseria gonorrhoeae from a piece of clothing. J Med Microbiol. 2007 Apr. 56:487-90. [Medline].

  27. Trent M, Haggerty CL, Jennings JM, Lee S, Bass DC, Ness R. Adverse adolescent reproductive health outcomes after pelvic inflammatory disease. Arch Pediatr Adolesc Med. 2011 Jan. 165(1):49-54. [Medline].

  28. Stefanelli P. Emerging resistance in Neisseria meningitidis and Neisseria gonorrhoeae. Expert Rev Anti Infect Ther. 2011 Feb. 9(2):237-44. [Medline].

  29. García PJ, Holmes KK, Cárcamo CP, et al. Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial. Lancet. 2012 Mar 24. 379(9821):1120-8. [Medline]. [Full Text].

  30. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med. 2005 May-Jun. 3(3):263-7. [Medline]. [Full Text].

  31. Meyers D, Wolff T, Gregory K, et al. USPSTF recommendations for STI screening. Am Fam Physician. 2008 Mar 15. 77(6):819-24. [Medline].

  32. Whiley DM, Tapsall JW, Sloots TP. Nucleic acid amplification testing for Neisseria gonorrhoeae: an ongoing challenge. J Mol Diagn. 2006 Feb. 8(1):3-15. [Medline]. [Full Text].

  33. 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. 1999 Nov. 37(11):3668-71. [Medline].

  34. Verzijl A, Berretty PJ, Erceg A, Krekels GA, Van den Brule AJ, Boel CH. [A pseudo-outbreak of pharyngeal gonorrhoea related to a false-positive PCR-result]. Ned Tijdschr Geneeskd. 2007 Mar 24. 151(12):689-91. [Medline].

  35. Wada K, Uehara S, Mitsuhata R, et al. Prevalence of pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae among heterosexual men in Japan. J Infect Chemother. 2012 Apr 11. [Medline].

  36. Muralidhar B, Rumore PM, Steinman CR. Use of the polymerase chain reaction to study arthritis due to Neisseria gonorrhoeae. Arthritis Rheum. 1994 May. 37(5):710-7. [Medline].

  37. Kimmitt PT, Kirby A, Perera N, et al. Identification of Neisseria gonorrhoeae as the causative agent in a case of culture-negative dermatitis-arthritis syndrome using real-time PCR. J Travel Med. 2008 Sep-Oct. 15(5):369-71. [Medline].

  38. 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. 2008 May. 35(5):517-20. [Medline].

  39. 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. 2008 Mar. 5(1):17-23. [Medline].

  40. 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. 2008 Jul 15. 47(2):e25-7. [Medline].

  41. 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. 2006 Dec. 82 Suppl 5:v29-32. [Medline].

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

  43. Unemo M, Shipitsyna E, Domeika M. Recommended antimicrobial treatment of uncomplicated gonorrhoea in 2009 in 11 East European countries: implementation of a Neisseria gonorrhoeae antimicrobial susceptibility programme in this region is crucial. Sex Transm Infect. 2010 Nov. 86(6):442-4. [Medline].

  44. Centers for Disease Control and Prevention. Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000--2010. MMWR Morb Mortal Wkly Rep. 2011 Jul 8. 60(26):873-7. [Medline].

  45. Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections. MMWR Morb Mortal Wkly Rep. 2012 Aug 10. 61:590-4. [Medline]. [Full Text].

  46. Brown T. Multidrug-Resistant Gonorrhea: New Treatment Guidelines. Available at http://www.medscape.com/viewarticle/779587. Accessed: February 27, 2013.

  47. Ota KV, Fisman DN, Tamari IE, et al. Incidence and treatment outcomes of pharyngeal Neisseria gonorrhoeae and Chlamydia trachomatis infections in men who have sex with men: a 13-year retrospective cohort study. Clin Infect Dis. 2009 May 1. 48(9):1237-43. [Medline].

  48. Melville NA. Two new antibiotics show efficacy in gonorrhea treatment. Medscape Medical News. July 16, 2013. [Full Text].

  49. Kirkcaldy R. Treatment of gonorrhoea in an era of emerging cephalosporin resistance and results of a randomised trial of new potential treatment options [abstract]. Sex Transm Infect. 89:A14-A15. [Full Text].

  50. The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Two New Promising Treatment Regimens for Gonorrhea. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/nchhstp/newsroom/2013/Gonorrhea-Treatment-Trial-PressRelease.html. Accessed: July 16, 2013.

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

  52. American Academy of Ophthalmology Cornea/External Disease Panel. Conjunctivitis. National Guideline Clearinghouse. 2008.

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

  54. Owusu-Edusei K Jr, Bohm MK, Chesson HW, Kent CK. Chlamydia screening and pelvic inflammatory disease: Insights from exploratory time-series analyses. Am J Prev Med. 2010 Jun. 38(6):652-7. [Medline].

  55. 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. 2008 Oct 7. 149(7):497-508, W96-9. [Medline].

  56. Barclay L. ACOG recommends expedited partner therapy for STIs. Medscape Medical News. WebMD Inc. Available at http://www.medscape.com/viewarticle/845221. May 22, 2015;

  57. [Guideline] American College of Obstetricians and Gynecologists. Committee opinion no 632: expedited partner therapy in the management of gonorrhea and chlamydial infection. Obstet Gynecol. 2015 Jun. 125 (6):1526-8. [Medline].

  58. Fletcher PS, Shattock RJ. PRO-2000, an antimicrobial gel for the potential prevention of HIV infection. Curr Opin Investig Drugs. 2008 Feb. 9(2):189-200. [Medline].

  59. CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010, Dec 17. 59(RR-12):1-110. [Full Text].

  60. Centers for Disease Control and Prevention. Neisseria gonorrhoeae with reduced susceptibility to azithromycin--San Diego County, California, 2009. MMWR Morb Mortal Wkly Rep. 2011 May 13. 60(18):579-81. [Medline].

  61. Department of Health and Human Services. Azithromycin resistance in Hawaii (May 24, 2011). Available at http://www.cdc.gov/std/gonorrhea/DCL-Azithro-GC-May-24-2011.pdf. Accessed: August 16, 2011.

  62. Kirkcaldy RD, Ballard RC, Dowell D. Gonococcal resistance: are cephalosporins next?. Curr Infect Dis Rep. 2011 Apr. 13(2):196-204. [Medline].

  63. Kunz AN, Begum AA, Wu H, et al. Impact of fluoroquinolone resistance mutations on gonococcal fitness and in vivo selection for compensatory mutations. J Infect Dis. 2012 Jun. 205(12):1821-9. [Medline].

  64. Availability of cefixime 400 mg tablets--United States, April 2008. MMWR Morb Mortal Wkly Rep. 2008 Apr 25. 57(16):435. [Medline].

  65. Ackerman AB. Hemorrhagic bullae in gonococcemia. N Engl J Med. 1970 Apr 2. 282(14):793-4. [Medline].

  66. Allen VG, Mitterni L, Seah C, Rebbapragada A, et al. Neisseria gonorrhoeae treatment failure and susceptibility to cefixime in Toronto, Canada. JAMA. 2013 Jan 9. 309(2):163-70. [Medline].

  67. Azariah S, Perkins N. Risk factors and characteristics of patients with gonorrhoea presenting to Auckland Sexual Health Service, New Zealand. N Z Med J. 2007 Apr 13. 120(1252):U2491. [Medline].

  68. 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. 2007 Apr 13. 56(14):332-6. [Medline]. [Full Text].

  69. Centers for Disease Control and Prevention (CDC). Increases in gonorrhea--eight western states, 2000--2005. MMWR Morb Mortal Wkly Rep. 2007 Mar 16. 56(10):222-5. [Medline].

  70. Chacko MR, Wiemann CM, Kozinetz CA, et al. New sexual partners and readiness to seek screening for chlamydia and gonorrhoea: predictors among minority young women. Sex Transm Infect. 2006 Feb. 82(1):75-9. [Medline]. [Full Text].

  71. Chen PL, Hsieh YH, Lee HC, et al. Suboptimal therapy and clinical management of gonorrhoea in an area with high-level antimicrobial resistance. Int J STD AIDS. 2009 Apr. 20(4):225-8. [Medline].

  72. 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.

  73. Driessen CM, de Jong SA, Bastiaens MT, Hissink Muller W, Weenink JJ, Spooren PF. [Dermatitis or arthritis as a sign of gonorrhoea]. Ned Tijdschr Geneeskd. 2011. 155:A2250. [Medline].

  74. Gonococcal Isolate Surveillance Project (GISP) Annual Report 2005. Sexually Transmitted Disease Surveillance 2005 Supplement. CDC. January 2007. [Full Text].

  75. Harth W, Linse R. Dermatological symptoms and sexual abuse: a review and case reports. J Eur Acad Dermatol Venereol. 2000 Nov. 14(6):489-94. [Medline].

  76. Laidman J. Gonorrhea Resistant to Cefixime Found in North America. Medscape Medical News. Jan 8, 2013. Available at http://www.medscape.com/viewarticle/777287. Accessed: February 12, 2013.

  77. Lewis DA. Global resistance of Neisseria gonorrhoeae: when theory becomes reality. Curr Opin Infect Dis. 2014 Feb. 27(1):62-7. [Medline]. [Full Text].

  78. Walters N, Butani L. A 16-year-old girl with recent disseminated gonococcemia now presenting with a facial rash. Ann Allergy Asthma Immunol. 2005 Feb. 94(2):224-7. [Medline].

 
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This patient presented with gonococcal urethritis, which became systemically disseminated, leading to gonococcal conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
Gonorrhea rates, United States, 1941-2009. Centers for Disease Control and Prevention.
Gonorrhea rates by race/ethnicity, United States, 2000-2009. Centers for Disease Control and Prevention.
Gonorrhea rates by age and sex, United States, 2009. Centers for Disease Control and Prevention.
Rates of gonococcal infection per 100,000 by state and outlying regions (2009). Data from the Centers for Disease Control and Prevention (CDC):
Disseminated gonococcemia, acral pustules.
Cytologic smear of cutaneous acral pustule showing gram-negative, intracellular diplococci.
 
 
 
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