eMedicine Specialties > Emergency Medicine > Infectious Diseases
Gonorrhea: Treatment & Medication
Updated: Oct 20, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.1
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.
For a CME activity, see 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.4
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
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime
Documented hypersensitivity
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.
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
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
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.
Adult
2 g IM once
Pediatric
40 mg/kg IM once
None reported
Documented hypersensitivity
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.
Adult
Not used for this indication
Pediatric
2 gtt OU into conjunctival sac once immediately after birth (no later than 1 h after delivery)
Decreases effects of sulfacetamide preparations
Documented hypersensitivity
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.
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)
None reported
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
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)
More on Gonorrhea |
| Overview: Gonorrhea |
| Differential Diagnoses & Workup: Gonorrhea |
 Treatment & Medication: Gonorrhea |
| Follow-up: Gonorrhea |
| References |
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References
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].
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].
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].
Availability of cefixime 400 mg tablets--United States, April 2008. MMWR Morb Mortal Wkly Rep. Apr 25 2008;57(16):435. [Medline].
Warner L, Stone KM, Macaluso M, et al. 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].
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].
MacDonald N, Mailman T, Desai S. Gonococcal infections in newborns and in adolescents. Adv Exp Med Biol. 2008;609:108-30. [Medline].
Ness RB, Smith KJ, Chang CC, et al. Prediction of pelvic inflammatory disease among young, single, sexually active women. Sex Transm Dis. Mar 2006;33(3):137-42. [Medline].
Peeling RW, Holmes KK, Mabey D, et al. Rapid tests for sexually transmitted infections (STIs): the way forward. Sex Transm Infect. Dec 2006;82 Suppl 5:v1-6. [Medline].
Peter NG, Clark LR, Jaeger JR. Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleve Clin J Med. Mar 2004;71(3):233-9. [Medline].
Ross JD. Systemic gonococcal infection. Genitourin Med. Dec 1996;72(6):404-7. [Medline].
Spigarelli MG. Urine gonococcal/Chlamydia testing in adolescents. Curr Opin Obstet Gynecol. Oct 2006;18(5):498-502. [Medline].
Thompson EC, Brantley D. Gonoccocal endocarditis. J Natl Med Assoc. Jun 1996;88(6):353-6. [Medline].
Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55:1-94. [Medline]. [Full Text].
Workowski KA, Berman SM, Douglas JM Jr. Emerging antimicrobial resistance in Neisseria gonorrhoeae: urgent need to strengthen prevention strategies. Ann Intern Med. Apr 15 2008;148(8):606-13. [Medline].
Further Reading
Keywords
gonorrhea, STD, sexually transmitted disease, Neisseria gonorrhoeae infection, N gonorrhoeae infection, gonococcal cervicitis, pelvic inflammatory disease, PID, salpingitis, endometritis, tubo-ovarian abscess, abdominal peritonitis, Fitz-Hugh-Curtis syndrome, epididymitis, epididymo-orchitis, conjunctivitis, disseminated gonococcal infection, DGI, neonatal eye infection, gonococcal urethritis, endocervicitis, human immunodeficiency virus, HIV, genital infections, migratory polyarthritis, septic arthritis, gonococcal endocarditis, gonococcal meningitis, penicillinase-producing N gonorrhoeae, PPNG, chronic pelvic pain, septic abortion, chorioamnionitis in pregnancy, infertility, ectopic pregnancy, child sexual abuse, viral hepatitis, pharyngitis, secondary gonococcal bacterialconjunctivitis, bilateral conjunctivitis, purulent conjunctivitis, ophthalmia neonatorum, neonatal gonococcal infection, purulent gonococcal arthritis, tenosynovitis, , vulvovaginitis, hemorrhagic lesions, erythema nodosum, urticaria, erythema multiforme, intrauterine device, IUD
