Emergent Management of Gonorrhea 

  • Author: Amy J Behrman, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Jul 27, 2011
 

Overview

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.

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Consultations

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.

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Antibiotic Treatment

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.

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Hospital Admission

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
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Further Outpatient Care

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.

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Deterrence/Prevention

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]

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Contributor Information and Disclosures
Author

Amy J Behrman, MD  Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine

Amy J Behrman, MD is a member of the following medical societies: American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Catherine T Shoff, DO  Staff Physician, Departments of Pulmonary, Critical Care and Sleep Medicine, Director, Tri-Services Adult Cystic Fibrosis Center, Wilford Hall Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Catherine T Shoff, DO is a member of the following medical societies: American Academy of Sleep Medicine and American College of Chest Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

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

Barry J Sheridan, DO  Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. 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.

  2. [Guideline] Centers for Disease Control and Prevention. 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].

  3. 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. Nov 2007;14(8):489-502. [Medline].

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

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

  6. 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. Jan 2006;33(1):36-51. [Medline].

  7. Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000--2010. MMWR Morb Mortal Wkly Rep. Jul 8 2011;60(26):873-7. [Medline].

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