Gonococcal Infections Treatment & Management

The decision to implement antimicrobial therapy should be made quickly. The choice of which regimen to use should be based on the clinical presentation.

Hospitalization is recommended for the initial treatment of disseminated gonococcal infection (DGI), purulent joint infections, meningitis, and endocarditis.

Hospitalization is also recommended for 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 diagnoses, with any possibility of ectopic pregnancy or appendicitis masquerading as PID
• Uncomplicated urethritis, cervicitis, or rectal or pharyngeal infection in adults

Treatment regimens ^[17]

Uncomplicated gonococcal infection of the urethra, cervix, or rectum

Summary is as follows:

• Ceftriaxone 250 mg IM single dose OR, IF NOT AN OPTION
• Cefixime 400 mg PO single dose OR
• Single-dose injectable cephalosporin regimens PLUS
• Azithromycin 1 g PO single dose OR
• Doxycycline 100 mg PO twice a day for 7 days

Effective single-dose regimens currently recommended as initial therapy by the US Public Health Service and the CDC in all patients in the United States are ceftriaxone (250 mg IM) or cefixime (400 mg PO).

The 250-mg intramuscular 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 intramuscular administration.

Data has indicated that the 400-mg oral dose of cefixime does not provide as high and not sustained bactericidal levels as compared with the 250-mg dose of ceftriaxone. In addition, based on findings from the Gonococcal Isolate Surveillance Project (GISP) reported July 2011, from 2009-2010 there has been decreasing susceptibility to cefixime.^[18]

Other single-dose cephalosporin therapies include ceftizoxime (500 mg IM), cefoxitin (2 g IM with probenecid 1 gorally), and cefotaxime 500 mg IM).

Other oral regimens proposed include cefpodoxime 400 mg orally and cefuroxime axetil 1 g orally. But both have certain caveats (see CDC guidelines for additional information).

Alternative regimens for patients intolerant of cephalosporins include spectinomycin (2 g IM) or single-dose cephalosporin regimens. Spectinomycin may be costly and is currently unavailable in the United States.

Fluoroquinolones, over the last decade, were the preferred class of antimicrobials for the treatment of gonorrhea; however, reports of N gonorrhoeae infection with decreasing susceptibilities and frank resistance have surfaced.

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP 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.^[19]

The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 250g IM once as a single dose). Fluoroquinolones may be an alternative treatment option for DGI if antimicrobial susceptibility can be documented. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.

Tetracyclines are no longer acceptable therapy for gonorrhea because of the prevalence of tetracycline-resistant strains. The frequency of such gonococcal strains is increasing and is up to 5%-15% in various US cities. Because gonococcal infections are very frequently associated with urogenital chlamydial infection, most authorities now recommend either single-dose azithromycin (1g PO) or a 7-day course of doxycycline (100 mg 2 times/day) as empiric treatment included with the cephalosporin therapy for gonorrhea.

Azithromycin at 2 g as a single dose is also effective; however, its use is limited by its cost, adverse gastrointestinal effects, lack of efficacy in pharyngeal infection, and growing concerns of resistance to macrolides (see Morbidity and Mortality Weekly Reports).^{[20, 21]} In addition, reports of growing macrolide resistance have been published, given that the 1-g (typically given in chlamydia treatment) exposure is sublethal for gonorrhea.

Gonococcal pharyngeal infections

Summary is as follows:

• Ceftriaxone 150 mg IM single dose PLUS
• Azithromycin 1 g PO single dose OR
• Doxycycline 100 mg PO twice a day for 7 days

Treat with ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days.

Gonococcal pharyngeal infections may be more challenging to eradicate than infections involving urogenital and anorectal areas.^[22]

Gonococcal arthritis

Recommended therapy is with ceftriaxone at 1 g/d IV/IM. Initial IV/IM treatment should be continued for 1-2 days after symptoms improve. At that time, it is a consideration to switch to cefixime 400 mg orally twice daily to complete a total course of 7 days of antibiotics.

Oral therapy may be used initially in carefully selected compliant patients with a definite diagnosis and only mild infection. Antibiotics for oral use in this situation include cefixime 400 mg twice a day for 7 days.

Gonococcal conjunctivitis

Treatment recommendations for adults are ceftriaxone 1 g IM with saline irrigation and topical antibiotic solutions.^[23]

Gonorrhea contributing to PID

Therapy for outpatients includes cefoxitin at 2 g IM plus probenecid at 1 g PO as a single dose or ceftriaxone at 250 mg IM followed by a 14-day oral regimen of doxycycline at 100 mg twice a day. Each of the above regimens may be accompanied by metronidazole 500 mg orally twice a day for 14 days. Also, examining and treating all sexual partners of women with gonococcal PID is crucial.

Therapy for hospitalized patients with PID consists of cefoxitin at 2 g parenterally every 6 hours or cefotetan at 2 g IV every 12 hours plus doxycycline. Alternative regimens for penicillin allergic patients include clindamycin 900 mg IV every 8 hours with gentamicin of loading dose 2 mg/kg of body weight followed by 1.5 mg/kg of body weight every 8 hours. Again, examining and treating all sexual partners of women with gonococcal PID is crucial.

Oral regimens for mild to moderately severe symptoms have been shown to be not inferior to intravenous regimens. The diagnosis should be reviewed and intravenous antibiotics administered in those in whom oral therapy fails after 72 hours.

Gonococcal epididymitis

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

Disseminated gonococcal infection

Summary is as follows:

• Ceftriaxone 1 g IM/IV every 24 hours
• Alternative regimens - Cefotaxime 1 g IV every 8 hours OR ceftizoxime 1 g IV every 8 hours

Cephalosporin-based regimens are recommended; intravenous therapy is recommended initially (for at least 24-48 hours, until clinical improvement) before transitioning to oral therapy.

Regimens include ceftriaxone 1 g IV every 24 hours or any of the alternative regimens listed by the CDC. Cefixime 400 mg orally twice daily is the preferred oral cephalosporin, once transitioned to oral therapy. The combination of intravenous and oral cephalosporin antibiotics should be administered.

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

Gonococcal meningitis and endocarditis

Recommended is ceftriaxone 1-2 g IV every 12 hours. Meningococcal meningitis therapy is recommended for 10-14 days, with endocarditis therapy recommended for a minimum of 4 weeks. Infectious disease consultation may be necessary.

See CDC STD treatment guidelines 2010 for treatment of gonococcal infection in children and the newborn.

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

• A gynecologist should be consulted for patients with severe PID and for any pregnant patient with an STD.
• A pediatrician should be consulted for any child with an STD.
• An ophthalmologist should be consulted for every patient with gonococcal conjunctivitis, as this disease may progress rapidly and can cause permanent loss of vision.
• An infectious disease specialist may be of benefit in cases of DGI or complicated disease courses.

• Patients with uncomplicated gonococcal disease can remain fully active.