eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Gonorrhea: Treatment & Medication
Updated: Aug 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The main decision once a diagnosis of gonorrhea has been made, either definitively or presumptively, is whether to treat as an outpatient or to hospitalize.
- For males, treatment is always outpatient for genital infection; however, admission may be necessary for complications such as disseminated gonococcal infection (DGI) or gonococcal arthritis.
- In females, the decision is much more difficult because the risk of complications is much higher. In light of high rates of noncompliance, reinfection, and poor follow-up, some clinicians advocate admitting whenever a question of a complication such as pelvic inflammatory disease (PID) is present, particularly in the adolescent population.
- Many institutions have attempted to quantify abnormalities found on pelvic examination (ie, the PID score) in an attempt to admit those patients with a higher likelihood of complications.
- In cases in which future fertility is at risk, most physicians are fairly aggressive, especially in situations in which the patient is very young or unfamiliar to them.
Consultations
- In cases of suspected rape or child abuse, seeking specialist help (in the form of specialist nurses or physicians) to interview and collect specimens (if necessary) for testing is prudent.
- Careful documentation of physical findings, even if apparently normal, is crucial for medicolegal reasons.
- Notification of child-protective services is required if abuse is suspected.
Medication
In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions.3 Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States and other parts of the world where resistance has become common, but they can be considered in areas where quinolone resistance has not yet emerged.
The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP).4 The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone resistant reached 6.7%, an 11-fold increase from 0.6% in 2001. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg intramuscularly once as a single dose).
Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection 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.
Antibiotic agents
Medical therapy requires an antibiotic with efficacy against N gonorrhoeae. Until several years ago, the treatment of choice involved oral medication for as long as 10 days or an injection; however, patients tend to be poorly compliant with medications for various reasons, and the availability of newer medications has allowed in-office, single-dose, oral treatment to ensure compliance.
Many practitioners presumptively treat patients after obtaining specimens for diagnosis, based on history and examination, because of the risk of poor follow-up, complications, and continuing spread to other partners. In addition, because gonorrhea is often simultaneously diagnosed with chlamydia , many practitioners treat patients for both diseases when treating for either beyond the newborn period. Diagnosis and treatment of the patient's partner and any partners of the partner are important to prevent reinfection and complications.
Disseminated or complicated infections (eg, endocarditis, meningitis) require more prolonged inpatient therapy. For example, ceftriaxone 50 mg/kg IV bid for 7 days plus a macrolide such as azithromycin administered for simple disseminated infection (10-14 d for meningitis or 28 d for endocarditis). Fluoroquinolones are no longer recommended for gonorrhea because of increased resistance.
If cephalosporins are not an option for disseminated gonorrhea or PID, fluoroquinolones may be considered if the local data suggests antimicrobial susceptibility. For these cases, an infectious disease consult is essential. Children older than 8 years may omit the macrolide in cases of endocarditis.
Information from the CDC states that 2 g of oral azithromycin is effective against uncomplicated gonococcal infection but is expensive, causes GI irritation, and is not recommended for treatment of gonorrhea. Although 1 g of azithromycin theoretically meets alternative regimen criteria, it is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance. N gonorrhoeae in the United States is not adequately susceptible to penicillins, tetracyclines, and macrolides (eg, erythromycin) for these antimicrobials to be recommended.3
Cefixime (Suprax)
DOC because of PO efficacy, single-dose treatment, and lower cost than parenteral medication. However, no longer manufactured in the United States and has limited availability.
Adult
400 mg PO once
Pediatric
Adolescents: Administer as in adults
May elevate carbamazepine levels; may cause false-positive chemical tests for ketonuria, glucosuria, and Coombs reaction
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects may include diarrhea, abdominal pain, nausea, and rashes; single-dose treatment is unlikely to cause ongoing problems because all adverse effects occur more commonly with prolonged courses of therapy
Ceftriaxone (Rocephin)
Second DOC because of higher cost, discomfort, and the additional administration expense of injection. Often used as first-line therapy when cefixime is unavailable.
Adult
Uncomplicated gonococcal infections: 125 mg IM once
Disseminated gonococcal infection: 1 g IV/IM qd for 7 d (10-14 days for meningitis); not to exceed 1 g/d; administer with azithromycin or erythromycin
Gonococcal endocarditis: 1-2 g/d IV/IM for 28 d
Epididymitis: 250 mg IM once; administer with 10 d of doxycycline
Conjunctivitis: 1 g IM with azithromycin or erythromycin
Pediatric
Uncomplicated gonococcal infection: 125 mg IM once
Disseminated gonococcal infection: 50 mg/kg/d IV/IM qd for 7 d (10-14 days for meningitis); not to exceed 1 g/d; administer in combination with azithromycin or erythromycin
Gonococcal endocarditis: 50 mg/kg/d IV/IM qd for 28 d; not to exceed 2 g/d
Conjunctivitis: 50 mg/kg IM once; not to exceed 1 g/d; administer with azithromycin or erythromycin
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 administration site reactions (eg, redness, pain) occur in 10-17% of adults
Spectinomycin (Trobicin)
Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and is structurally different from related aminoglycosides. May be used in instances of allergy to cephalosporins.
Adult
2 g IM as a single dose
Pediatric
Infants and children: 40 mg/kg IM as a single dose; not to exceed 2 g (with erythromycin or azithromycin to treat chlamydia)
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 mo; monitor clinical effectiveness to detect resistance by N gonorrhea
Erythromycin (E-Mycin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult
Not recommended
Pediatric
50 mg/kg/d (as base) PO divided qid for 10-14 d; not to exceed 2 g/d (for chlamydia, administer with ceftriaxone or spectinomycin)
Inhibits CYP450 3A4; coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats mild to moderate microbial infections.
Information from the CDC state that azithromycin 2 g PO is effective against uncomplicated gonococcal infection, but is expensive and causes GI irritation and is not recommended for treatment of gonorrhea. Although azithromycin 1 g theoretically meets alternative regimen criteria, it is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance.
Adult
Nongonococcal urethritis and cervicitis: 1 g PO once (for chlamydia, administer with cefixime or ceftriaxone)
Second-line treatment for gonococcal urethritis and cervicitis (monotherapy): 2 g PO once
Pediatric
Infants and children: 20 mg/kg PO as a single dose; not to exceed 1 g (with ceftriaxone or spectinomycin)
Adolescents: 1 g PO once (for chlamydia, administer with cefixime or ceftriaxone)
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients; nausea, vomiting, and GI irritation may occur, particularly with large doses (ie, 2 g)
Doxycycline (Bio-Tab, Vibramycin, Doryx)
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for 7 d (for chlamydia, administer with cefixime or ceftriaxone)
Pediatric
Adolescents: 100 mg PO bid for 7 d (for chlamydia, administer with cefixime or ceftriaxone)
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
More on Gonorrhea |
| Overview: Gonorrhea |
| Differential Diagnoses & Workup: Gonorrhea |
 Treatment & Medication: Gonorrhea |
| Follow-up: Gonorrhea |
| Multimedia: Gonorrhea |
| References |
| « Previous Page | Next Page » |
References
CDC. STD Surveillance 2007, Gonorrhea. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/STD/stats07/gonorrhea.htm. Accessed 3/28/09.
Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE Jr, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health. Jul 2009;45(1):8-24. [Medline].
[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].
Gonococcal Isolate Surveillance Project (GISP) Annual Report 2005. Sexually Transmitted Disease Surveillance 2005 Supplement. CDC; January 2007. [Full Text].
American Academy of Pediatrics. 2006 Red book: Report of the committee on infectious diseases. 27th ed. 2006:301-9.
Behrman RE. Nelson's Textbook of Pediatrics. 14th ed. Philadelphia, PA: WB Saunders Co; 1992:536-7.
Blake D, Woods E. The future is here: Noninvasive diagnosis of STDs. Contemp Pediatr. Feb 2001;71-87.
Bruckner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health. 2005;4:271-8. [Medline]. [Full Text].
CDC. Increases in gonorrhea--eight western states, 2000--2005. MMWR Morb Mortal Wkly Rep. Mar 16 2007;56(10):222-5. [Medline].
[Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
Kerr-Layton JA, Stamm CA, Peterson LS. Chronic plasma cell endometritis in hysterectomy specimens of HIV- infected women: a retrospective analysis. Infect Dis Obstet Gynecol. 1998;6(4):186-90. [Medline].
McCormack WM. Pelvic inflammatory disease. N Engl J Med. Jan 13 1994;330(2):115-9. [Medline].
Palusci VJ, Reeves MJ. Testing for genital gonorrhea infections in prepubertal girls withsuspected sexual abuse. Pediatr Infect Dis J. Jul 2003;22(7):618-23. [Medline].
Further Reading
Keywords
gonorrhea, GC, neisserial infections, the clap, sexually transmitted diseases, STD, Neisseria gonorrhoeae, gonococcal urethritis, pelvic inflammatory disease, PIC, urethritis, cervicitis, epididymitis, pharyngitis, proctitis, sexual abuse, septic arthritis, perihepatitis, Fitz-Hugh-Curtis syndrome, disseminated gonococcal infection, DGI, conjunctivitis, ophthalmia neonatorum, peritonitis, tuboovarian abscess, tubal perforation, ectopic pregnancy, urethral discharge, dysuria, dyspareunia, chlamydia, herpes, hepatitis B, syphilis, human immunodeficiency virus, HIV
