eMedicine Specialties > Emergency Medicine > Infectious Diseases

Gonorrhea

Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine
William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

Updated: Nov 12, 2009

Introduction

Background

Gonorrhea is a purulent infection of mucous membrane surfaces caused by a sexually transmitted microorganism, Neisseria gonorrhoeae. Virtually any mucous membrane can be infected by this highly infectious, gram-negative diplococcal organism.
 
Gonococcal infections following sexual and perinatal transmission are a major source of morbidity worldwide. In the developed world, where prophylaxis for neonatal eye infection is standard, the vast majority of infections follow genitourinary mucosal exposure. Infections can involve cervicitis, proctitis, urethritis, pelvic inflammatory disease, and pharyngitis. Complications include ectopic pregnancy and increased susceptibility to HIV.

Pathophysiology

The pathophysiology of N gonorrhoeae and the relative virulence of different subtypes depend on the antigenic characteristics of the respective surface proteins. Certain subtypes are able to evade serum immune responses and are more likely to lead to disseminated (systemic) infection.
 
Well-characterized plasmids commonly carry antibiotic-resistance genes, most notably penicillinase. Plasmid and nonplasmid genes are transmitted freely between different subtypes. The ensuing exchange of surface protein genes results in high host susceptibility to reinfection. The exchange of antibiotic resistance genes has led to extremely high levels of resistance to beta-lactam antibiotics over the last 2 decades. More recently, fluoroquinolone resistance has also been documented on multiple continents and in widespread populations within the United States.

Infection of the lower genital tract, the most common clinical presentation, primarily manifests as male urethritis and female endocervicitis. Infection of the pharynx, rectum, and female urethra occur frequently but are more likely to be asymptomatic or minimally symptomatic. Retrograde spread of the organisms occurs in as many as 20% of women with cervicitis, often resulting in pelvic inflammatory disease (PID), with salpingitis, endometritis, and/or tubo-ovarian abscess. Retrograde spread can lead to frank abdominal peritonitis and to a perihepatitis known as Fitz-Hugh-Curtis syndrome.

Long-term sequelae of PID, such as tubal factor infertility, ectopic pregnancy, and chronic pain, may occur in up to 25% of affected patients. Epididymitis or epididymo-orchitis may occur in men after gonococcal urethritis. Lower genital infection is a risk factor for the presence of other sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV).
 
Conjunctivitis can occur in adults as well as in children following direct inoculation of organisms and can lead to blindness.
 
Disseminated gonococcal infection (DGI) occurs following approximately 1% of genital infections. Patients with DGI may present with symptoms of rash, fever, arthralgias, migratory polyarthritis, septic arthritis, tendonitis, tenosynovitis, endocarditis, or meningitis. Three fourths of the cases of DGI occur in women; susceptibility is increased if the primary mucosal infection occurs during menstruation or pregnancy. Changes in the vaginal environment at these times may foster changes in the gonococcal surface features and phenotype that render the organisms more resistant to host defenses in the bloodstream and more likely to disseminate.

Frequency

United States

N gonorrhoeae has been the most common STD worldwide for at least most of the 20th century, with an estimated 200 million new cases annually. Public health initiatives in the developed world have resulted in declining incidence of the disease since the mid 1970s, but gonorrheal infection is still the second most common notifiable disease in the United States. More than 350,000 cases were reported in the United States in 2007,¹ but that number may underestimate the true case rate by 50% due to underdiagnosis and underreporting.

The incidence of antibiotic-resistant strains has been rising since the late 1940s. Of greatest concern historically was the high percentage of cases due to penicillinase-producing N gonorrhoeae (PPNG). However, fluoroquinolone resistance has increased rapidly over the past decade on most continents and within the United States. The CDC reported fluoroquinolone resistance in 6.8% of 2004 isolates, 9.4% of 2005 isolates, and 13.3% of 2006 isolates.²

International

Approximately 200 million new cases of gonorrhea occur each year.

Mortality/Morbidity

• The most common long-term sequelae of gonorrhea are chronic pelvic pain in women after PID, septic abortion, chorioamnionitis in pregnancy, blindness after neonatal or adult conjunctivitis, and infertility of either sex.
• Ectopic pregnancy is a life-threatening complication that may follow scarring of the female upper reproductive tract from PID.
• Disseminated infection may lead to meningitis or endocarditis.

Race

• Race has no intrinsic effect on susceptibility, but, in the United States, the disease is most commonly diagnosed among the urban poor and minorities. This may reflect bias due to data collection site preference (eg, urban EDs and STD clinics) as well as true differences in prevalence.
• All sexually active populations are at risk and the level of risk rises with the number of sex partners and the presence of other STDs.

Sex

• Gonococcal infections are 1.5 times more common in men than in women.
• Gonococcal infections rates are higher among men who have sex with men (MSM).
• Serious sequelae are much more common in women, in whom PID may lead to ectopic pregnancy or infertility and for whom DGI is more likely.

Age

• Gonococcal infections are diagnosed most frequently in adolescents and young adults.¹
• Infection in children is a marker for child sexual abuse and should be reported as such, although a recent review provided some support for nonsexual transmission between children and for transmission from adults to children related to poor hand hygiene.³

Clinical

History

In all patients presenting with possible STDs, history should include history of STDs (including HIV and viral hepatitis), known symptoms of STDs in current or past partners, type of contraception used, and any history of sexual assault. In women, the history also should include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.

Genitourinary tract, male

• Urethral discomfort, dysuria, and discharge due to uncomplicated urethritis are the most common symptoms in men. Degree of discomfort and discharge are variable, and subjective symptoms may be absent.
• The classic presentation of epididymitis is of unilateral pain and swelling localized posteriorly within the scrotum. N gonorrhoeae and Chlamydia trachomatis account for most cases of epididymitis in men younger than 35 years.
• Urethral strictures due to gonococcal infection are now uncommon in the antibiotic era, but they can present with decreased and abnormal urine stream as well as with the secondary complications of prostatitis and cystitis.
• Rectal infection may present with pain, pruritus, discharge, or tenesmus.
• A significant percentage of men and women with gonorrhea also have pharyngitis, which usually is asymptomatic but may cause mild-to-severe dysphagia and discomfort.
• Secondary gonococcal bacterial conjunctivitis may follow accidental inoculation by fingers in either sex and is usually unilateral.

• Vaginal discharge from endocervicitis is the most common presenting symptom. The discharge usually is described as thin, purulent, and mildly odorous. Many patients have minimal or no symptoms from gonococcal cervicitis.
• Dysuria or a scant urethral discharge may be due to urethritis accompanying cervicitis.
• Pelvic or lower abdominal pain suggests ascending infection of the endometrium, fallopian tubes, ovaries, and peritoneum. Pain may be midline, unilateral, or bilateral. Fever, nausea, and vomiting may be present. The possibility of ectopic pregnancy should always be considered in patients with pelvic or lower abdominal pain.
• Right upper quadrant pain from perihepatitis (Fitz-Hugh-Curtis syndrome) may occur following the spread of organisms upward along peritoneal planes. 
• Rectal infection is often asymptomatic, but rectal pain, pruritus, tenesmus, and rectal discharge may be present if the rectal mucosa is infected. Bloody diarrhea also may occur. Rectal infection may occur from anal intercourse, and, in women, by local spread of the organism.  

Ophthalmologic, infants 

• In neonates, bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery by an infected mother without treatment. The symptoms of gonococcal conjunctivitis are eye pain, redness, and a purulent discharge.
• The organism can cause permanent injury to the eye in a very short time; prompt recognition and treatment are essential to avoid blindness. Blindness from neonatal gonococcal infection is a serious problem in developing countries but is uncommon in the United States and other countries where neonatal prophylaxis is routine. Nevertheless, infants of mothers with untreated infections, poor prenatal care, and unmonitored births continue to be at risk.

Disseminated gonorrheal infection 

• Disseminated gonococcal infection (DGI) may follow 1-2% of mucosal infections, with symptoms that vary greatly from patient to patient. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection.
• DGI can occur in infants born to infected mothers.
• Joint or tendon pain is the most common presenting complaint. About 25% of patients with DGI complain of pain in a single joint, while as many as two thirds describe polyarthralgia, which is often migratory. Severe pain, swelling, and decreased mobility in a single joint suggest a purulent arthritis with effusion. The knee is the most common site of purulent gonococcal arthritis.
• Tenosynovitis is also common in DGI, usually affecting the small joints of the hands.
• Fever is common, but the temperature is usually less than 39°C.
• Skin rash is a presenting complaint in approximately 25% of patients, but a careful examination will reveal a rash in most patients with DGI. The rash is usually found below the neck and may also involve the palms and soles.
• Headache, neck pain and stiffness, fever, and decreased sensorium may indicate gonococcal meningitis. This disease may be clinically indistinguishable from meningococcal meningitis on presentation, although the course of gonococcal meningitis usually is less rapid.
• Subacute onset of fever, chills, sweats, and malaise may indicate the presence of gonococcal endocarditis. Patients with endocarditis may develop atypical chest pain, cough, and dyspnea, as well as the arthralgias and rash typical of DGI. Rarely, gonococcal endocarditis can cause severe valvular damage and death if not recognized and treated rapidly. Gonococcal endocarditis is more common in men than in women. Patients with collagen vascular disease (especially those with systemic lupus erythematosus) also may be more prone to this complication.

Physical

N gonorrhoeae infection may be recognized by the typical signs and symptoms of the disease, but it is important to remember that, by the time disseminated or upper reproductive tract disease is present, the primary site of mucosal infection may be normal in appearance, and the patient may have no localized signs or symptoms.
 
Genitourinary tract, male   

• Mucopurulent or purulent urethral discharge
• Unilateral epididymal tenderness and edema

Lower genitourinary tract, female 

• Mucopurulent or purulent cervical discharge
• Vaginal discharge or bleeding; vulvovaginitis in children

• PID symptoms  
• Lower abdominal tenderness with or without rebound tenderness        
• Cervical motion tenderness
• Adnexal tenderness, unilateral or bilateral
• Fever
• Upper right abdominal tenderness (with perihepatitis)

• Mucopurulent or purulent discharge

Oropharyngeal 

• Pharyngitis, usually mild

Ophthalmologic

• Purulent conjunctivitis is usually bilateral in ophthalmia neonatorum but most often is unilateral when secondary to self-inoculation in older patients.

Disseminated gonococcal infection 

DGI may present with any of the following findings:

• Fever (usually temperature <39°C)
• Skin: Maculopapular, pustular, necrotic, or vesicular rash, typically occurring on the torso, limbs, palms, and soles may be present. The rash usually spares the face, scalp, and mouth. Hemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently. Skin lesions are usually in different stages of development at the time of clinical presentation.
• Joints: Most patients may have polyarthralgia with joint tenderness, decreased range of motion, and erythema. Less often, purulent arthritis may affect a single joint with severe pain, tenderness, edema, erythema, and decreased range of motion.
• Tenosynovitis presents as erythema and local tenderness along a tendon sheath, with pain on active or passive range of motion. Tenosynovitis most often occurs in the hands but may be found in the tendons of the lower extremities as well.
• Central nervous system: Patients with gonococcal meningitis may present with meningismus or decreased mental status.
• Cardiac: Patients with gonococcal endocarditis may have a new murmur, tachycardia, and fever. Embolic lesions may be present.
• Muscle: DGI can cause abscess formation within the soft tissues, presenting as localized tenderness, edema, and pain with motion.

Causes

• Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact. It also may be due to inoculation of mucosa by contaminated fingers or other objects.
• Neonatal infection may follow conjunctival inoculation during birth or direct infection through the scalp at the sites of fetal monitoring electrodes.

Risk factors 

• Sexual exposure to an infected individual without barrier protection
• Multiple sexual partners
• Infants - Passage through the infected birth canal of the mother
• Children - Sexual abuse by an infected individual, possibly nonsexual contact in household or institutional settings
• PID - Use of an intrauterine device (IUD)

Differential Diagnoses

Other Problems to Be Considered

Inflammatory arthritis
Septic arthritis
Herpes simplex urethritis
Mucopurulent cervicitis
Nongonococcal conjunctivitis
Nongonococcal endocarditis
Nongonococcal meningitis
Nongonococcal urethritis

Workup

Laboratory Studies

Laboratory studies for suspected gonorrhea may include the following:

• Gram stain
  • Gram stain is a rapid and inexpensive test available in many EDs.
  • Positive predictive value is high for urethral infection, but a negative Gram stain does not rule out infection in asymptomatic men.
  • Sensitivity and specificity of the Gram stain are lower for endocervical specimens and rectal specimens. Gram stains from these sites are not recommended for routine use in the ED.
  • The test is not useful for the diagnosis of pharyngeal infection because the oropharynx may be colonized by other Neisseria species that can lead to false-positive results. 
• Culture
  • Specific culture of a swab from the site of infection is a criterion standard for diagnosis at all potential sites of infection and can potentially guide treatment by determining antibiotic susceptibility.
  • N gonorrhoeae is a fastidious organism that requires moist carbon dioxide-rich atmosphere and must be grown on enriched media, usually chocolate agar containing lysed blood.
  • Empiric treatment is often necessary because culture results are not available for 24-48 hours.
  • Cultures are particularly useful when the clinical diagnosis is unclear, when a failure of treatment has occurred, when contact tracing is problematic, and when legal questions arise.
• Nucleic acid amplification tests
  • Nucleic acid amplification tests (NAATs) are designed to amplify sequences of DNA unique to a given pathogen, such as N gonorrhoeae. These tests are more sensitive and specific than nonamplification techniques.
  • Several FDA-approved NAATs are available for the detection of N gonorrhoeae in urethral swab specimens obtained from males, endocervical swabs, and urine specimens obtained from men and women. These tests are more rapid than culture, more specific than immunoassays, and do not require viable organisms.⁴
  • NAATs may be of particular use when examination and mucosal swab are difficult (in children or extremely apprehensive patients), and urine specimens are more easily obtained.
  • NAATs can be used on eye secretions, but their performance is less well validated. NAATs are not all recommended for rectal and pharyngeal specimens at this time.
  • Clinicians should be familiar with specimen collection guidelines and performance parameters of the test available at their own hospitals.
• Suspected DGI
  • When DGI is suspected, blood and joint effusions should be sent for Gram stain and culture, although negative stain results and sterile cultures do not rule out disseminated disease. Cerebrospinal fluid should be stained and cultured if signs or symptoms of meningitis are present.
  • Gram stains, cultures, and/or nucleic acid amplification tests (NAATs) of genital, rectal, conjunctival, and pharyngeal secretions should also be obtained when DGI is suspected, even if the patient has no localized symptoms at any of those sites.
• Tests to identify other STDs
  • All patients with a likely diagnosis of gonorrheal infection should be tested for syphilis and C trachomatis.
  • Testing for HIV may be indicated. Rapid HIV test technology makes ED testing and referral more practical than enzyme-linked immunosorbent assay (ELISA).
  • Physical examination should always include scrutiny for signs of herpes simplex, syphilis, chancroid, lymphogranuloma venereum, and genital warts.
  • Pregnancy test should always be obtained for women of childbearing age who present with gonorrhea or any other STD.

Imaging Studies

• Ultrasonography
  • Pelvic ultrasonography or CT scan may demonstrate thick, dilated fallopian tubes or abscess formation.
  • PID is uncommon in pregnancy when the cervical mucous plug may provide some protection to the upper tract. Ultrasonography should be used to rule out ectopic pregnancy whenever a pregnant patient has signs and symptoms of possible PID. See Pregnancy, Ectopic .

Procedures

• Collect specimens from the urethra, endocervix, pharynx, rectum, conjunctiva, urine, or blood; in addition, perform lumbar puncture and joint aspiration if indicated by clinical findings.
• Culdocentesis, although rarely indicated, may demonstrate free purulent exudate and provide material for Gram stain and culture.

Treatment

Emergency Department Care

• 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 be sufficient to treat both infections.
• Gonococcal infection in HIV-positive patients is treated with the same regimen used for the general population.
• Specimens from likely sites of infection should be sent to the laboratory to be cultured for N gonorrhoeae and Chlamydia species. NAATs may be used in addition to or in place of culture depending on availability and laboratory preferences. The possibility of other STDs should be evaluated.
• 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.
• Pain relief may be needed for patients with epididymitis, PID, and DGI.
• Aspiration of purulent joint effusions may improve the patient’s comfort and recovery.
• Counsel patients to abstain from sexual activity until after full treatment and testing and treatment of partners is complete.

Consultations

• Consult a gynecologist for patients with severe PID and for any pregnant patient with an STD.
• Consult a pediatrician for any child with an STD.
• Consult an ophthalmologist for every patient with gonococcal conjunctivitis, as this disease may progress rapidly and can cause permanent loss of vision.

Medication

Historically the treatment of choice for gonorrhea has been oral medication for up to 10 days or an injection. Newer medications allowing in-office/in-ED, directly observed, single-dose oral treatment overcome poor patient compliance. In addition, because gonorrhea is often diagnosed simultaneously with chlamydia, the clinician should treat for both upon diagnosis of either when treating for either beyond the newborn period. Partner diagnosis and treatment is important to prevent reinfection and complications.

In April 2007, the Centers for Disease Control and Prevention (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. 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 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.²

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.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefixime (Suprax)

The DOC because of oral efficacy, single-dose treatment, and lower cost than parenteral medication. Cefixime inhibits bacterial cell wall synthesis by binding to one or more of the PBPs. After a period of unavailability, oral cefixime is now available again in the United States, in tablet and suspension, for the treatment of uncomplicated urogenital or rectal gonorrhea.⁵

Dosing

Adult

400 mg PO once for uncomplicated genitourinary or rectal infection

Pediatric

<45 kg: 8 mg/kg PO once; not to exceed 400 mg
>45 kg: Administer as in adults

Interactions

Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not effective against pharyngeal gonococcal infection and not recommended for PID
Adverse effects, including diarrhea, abdominal pain, nausea, and rashes, occur more commonly with prolonged courses of therapy; single-dose treatment is unlikely to cause ongoing problems
Caution in documented hypersensitivity to penicillins or reduced renal function
Administer with food to minimize GI adverse effects
Adjust dose in renal impairment

Ceftriaxone (Rocephin)

DOC for DGI, outpatient PID, and pharyngeal infection. Secondary DOC for uncomplicated genitourinary infections, but only because of higher cost, discomfort, and additional administration expense of injection.
Ceftriaxone binds to PBPs inhibiting bacterial cell wall growth.

Dosing

Adult

125-250 mg IM once; 125 mg if uncomplicated genitourinary, rectal, or pharyngeal infection; 250 mg for PID
1 g IV/IM q24h for DGI
1-2 g IV q12h for gonococcal meningitis or endocarditis
1 g IM once for gonococcal conjunctivitis; consider single saline lavage as well

Pediatric

25-50 mg/kg IV/IM as single dose for conjunctival infection (maximum 125 mg)
25-50 mg/kg/d IV/IM for 7 d for scalp abscess, sepsis, arthritis
25-50 mg/kg/d IV/IM for 10-14 d for suspected or known meningitis
125 mg IM once for children <45 kg with uncomplicated urethritis, cervicitis, pharyngitis, or rectal infection
>45 kg: Administer as in adults

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Local site reactions (redness, pain) in 10-17% of adults (using 1% lidocaine as a diluent may reduce discomfort); caution with history of penicillin allergy or gallbladder, biliary tract, and hepatic disease; nephrotoxicity, similar to cephalosporins, is possible cause of pseudomembranous colitis; adjust dose in renal impairment; caution in breastfeeding women and in those with allergy to penicillin

Spectinomycin (Trobicin)

Indicated for patients with beta-lactam intolerance, but second-line choice due to poor efficacy in pharyngitis.

Dosing

Adult

2 g IM once

Pediatric

40 mg/kg IM once

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Benzyl alcohol used as a diluent associated with fatal gasping syndrome in infants; antibiotics may mask or delay symptoms of incubating syphilis; perform a serologic test for syphilis in all patients with gonorrhea at time of diagnosis followed by additional test after 3 months; monitor clinical effectiveness to detect resistance by N gonorrhoeae

Silver nitrate

Inhibit growth of both gram-positive and gram-negative bacteria. Germicidal effects are attributed to precipitation of bacterial proteins by liberated silver ions.

Dosing

Adult

Not used for this indication

Pediatric

2 gtt OU into conjunctival sac once immediately after birth (no later than 1 h after delivery)

Interactions

Decreases effects of sulfacetamide preparations

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Repeated application into eye can cause cauterization of cornea and blindness

Erythromycin (Erygel)

Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Dosing

Adult

Not used for this indication

Pediatric

Apply 0.5-inch (1.25 cm) ribbon OU into conjunctival sac once immediately after birth (no later than 1 h after delivery)

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, or fungal infections of eye; patients using steroid combinations after uncomplicated removal of a foreign body from cornea should avoid using this product

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)

Follow-up

Further Inpatient Care

• Hospitalization is recommended for initial treatment of disseminated gonococcal infection (DGI) (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

Further Outpatient Care

• Patients with DGI or PID 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.

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 and should be recommended.⁶

Complications

Complications from gonococcal infection may include the following:

• Urethral scarring in men possibly leading to decreased fertility or to bladder-outlet obstruction
• Scarring of the upper reproductive tract in women with PID possibly leading to infertility, chronic pelvic pain, and ectopic pregnancy
• Possible prematurity, neonatal infection, and miscarriage resulting from gonococcal infections in pregnant women
• Possible corneal scarring and permanent vision impairment or blindness resulting from gonococcal ophthalmic infection
• Possible sepsis in infants following neonatal exposure to maternal gonorrhea
• Possible permanent neurologic sequelae resulting from gonococcal meningitis
• Destruction of joint articular surfaces
• Destruction of cardiac valves
• Death from congestive heart failure (CHF) or meningitis

Prognosis

• Most gonococcal infections respond quickly to cephalosporin therapy.
• Prognosis is excellent if therapy is initiated promptly and completed.

Patient Education

• Patients should be counseled about the risks of complications following gonococcal infection and the risk of other STDs.
• Patients always should be instructed to refer any sex partners for prompt evaluation and treatment.
• Patients should avoid sexual contact until medication is finished 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.
• Patient education materials are also available at Centers for Disease Control and Prevention (CDC) Web site (Sexually Transmitted Diseases – Gonorrhea) and from many local public health departments.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose surgical emergencies, such as ectopic pregnancy or appendicitis, in patients with a clinical diagnosis of PID
• Failure to treat for co-infection with chlamydia
• Failure to instruct patients to refer partners for treatment
• Failure to evaluate pediatric infections as cases of child sexual abuse
• Failure to evaluate the possibility of abuse in cases involving incapacitated or elderly patients
• Failure to send cultures to confirm the clinical diagnosis in cases with associated legal issues
• Failure to send cultures and begin prophylactic treatment following sexual assault
• Failure to recognize those patients who require hospitalization and inpatient therapy

References

1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Surveillance, 2007. Last updated January 2009. Available at http://www.cdc.gov/std/stats07/gonorrhea.htm. Accessed November 12, 2009.

2. [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. 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].

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

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7. Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. Jul 17 2007;147(2):89-96. [Medline].

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Keywords

gonorrhea, gonorrhea symptoms, gonorrhea treatment, gonorrhea causes, STD, sexually transmitted disease, Neisseria gonorrhoeae infection, infection, gonococcal cervicitis, disseminated gonococcal infection, gonococcal urethritis

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)

William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Glaxo Smith Kline Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Medical Editor

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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical 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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier 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.

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