Emergent Management of Gonorrhea 

In emergency department (ED) patients who clinical presentation suggests gonorrhea, specimens from likely sites of infection should be sent to the laboratory to be cultured for N gonorrhoeae and Chlamydia species. Nucleic acid amplification tests (NAATs) may be used in addition to or in place of culture depending on availability and laboratory preferences.^[4] The possibility of other sexually transmitted diseases (STDs) should be evaluated.

Begin appropriate antibiotic therapy for gonorrhea as soon as possible. Chlamydial infection is found frequently in patients with gonorrhea; thus, empiric antibiotic therapy should always provide coverage for both infections in any patients other than newborns. Gonococcal infection in HIV-positive patients is treated with the same regimen used for the general population.

Pain relief may be needed for patients with epididymitis, pelvic inflammatory disease, and disseminated gonococcal infection (DGI). Aspiration of purulent joint effusions may improve the patient’s comfort and recovery.

Partner diagnosis and treatment is important to prevent reinfection and complications. Counsel patients to abstain from sexual activity until after full treatment and testing and treatment of partners is complete. Patients should receive information and counseling to help them avoid future STDs and unwanted pregnancies.

Social services should be consulted immediately in cases of suspected sexual assault, child abuse, or elder abuse. Clinicians should be aware, however, that gonorrhea can be transmitted to children nonsexually (eg, spread of infection can occur via contaminated hands of infected caregivers).^[3]

For more information, see the Medscape Reference topic Gonorrhea.

Consult a gynecologist for patients with severe pelvic inflammatory disease and for any pregnant patient with a sexually transmitted infection (STD). Consult a pediatrician for any child with an STD.

Consult an ophthalmologist for every patient with gonococcal conjunctivitis. This disease may progress rapidly and can cause permanent loss of vision.

Historically, the treatment of choice for gonorrhea has been oral medication for up to 10 days or an injection. Newer single-dose oral regimens, which can be given in the office or emergency department under direct observation, eliminate the problem of poor patient compliance.

Since 2007, the Centers for Disease Control and Prevention (CDC) has not recommended fluoroquinolone antibiotics for the treatment of gonorrhea in the United States. However, the CDC advises that fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.^[2]

Cefixime

This limits recommended treatment of gonorrhea to drugs in the cephalosporin class.^[1] Cefixime (Suprax) is the drug of choice for the treatment of uncomplicated urogenital or rectal gonorrhea,^[5] because of oral efficacy, single-dose treatment, and lower cost than parenteral medication. After being unavailable in the United States from 2002 to 2008, oral cefixime is currently marketed in both tablet and suspension form Choices include oral or (eg, ceftriaxone 125 mg IM once as a single dose).

Ceftriaxone

Ceftriaxone (Rocephin) is the drug of choice for disseminated gonococcal infection, pelvic inflammatory disease, and pharyngeal infection. It is the second-line agent for uncomplicated genitourinary infections, but only because of higher cost, along with the discomfort and additional administration expense of injection.

Drug resistance

Although cephalosporins remain an effective treatment for gonococcal infections, the CDC has reported that resistance to cefixime increased from 0.2% in 2000 to 1.4% in 2010, and resistance to ceftriaxone increased from 0.1% to 0.3% in 2010 during that period.^[7]

Spectinomycin

Spectinomycin (Trobicin) is indicated for patients with beta-lactam intolerance. It is a second-line choice due to poor efficacy in pharyngitis.

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.

Hospitalization is recommended for initial treatment of disseminated gonococcal infection (especially for patients who are unlikely to return for follow-up doses of antibiotics), purulent joint infections, meningitis, and endocarditis.

Hospitalization is recommended for initial treatment of pelvic inflammatory disease (PID) cases in the presence of the following factors:

• Tubo-ovarian abscess
• Pregnancy
• Failure of outpatient treatment
• Severe symptoms, such as severe pain, high fever, or persistent nausea and vomiting
• Immunodeficiency
• Gonococcal conjunctivitis
• Uncertain diagnosis, with any possibility of ectopic pregnancy or appendicitis masquerading as PID
• Abdominal peritonitis or perihepatitis

Patients with disseminated gonococcal infection or pelvic inflammatory disease who are treated on an outpatient basis must receive follow-up care within 72 hours. Early follow-up care and culture with antibiotic sensitivities is indicated for patients with unresolved or recurrent symptoms.

Follow-up for test of cure is indicated for all pharyngitis cases treated with spectinomycin, as its efficacy is less than 60%.

Instruct patients with uncomplicated cases to follow up with a primary care or public health provider to reduce the risk of future infection.

All patients with gonococcal infection should refer all their sex partners (whether symptomatic or asymptomatic) for evaluation and treatment.

All infants born to mothers with untreated gonococcal infection should be treated prophylactically with a single dose of ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 mg. All neonates should undergo prophylaxis for ophthalmia neonatorum with silver nitrate (1%) aqueous solution OU once or erythromycin (0.5%) ophthalmic ointment OU once.

Condoms offer partial protection against gonococcal infection and should be recommended.^[6]