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Gonococcal Infections

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  • Children >45 kg same dosing as adults (1,2 and 3)[A]
  • Children <45 kg: uncomplicated urethral, cervical, rectal or pharyngeal gonococcal infections (1,2 and 3)[A]
  • Ophthalmic neonatorum prophylaxis: single application of erythromycin 0.5% ophthalmic ointment to each eye immediately after delivery (1,2 and 3)[A]
  • Neonatal conjunctivitis: ceftriaxone 25 to 50 mg/kg IV or IM in a single dose (not to exceed 125 mg) (1,2 and 3)[A]
  • Conjunctival exudates should be cultured for definitive diagnosis (1,2 and 3)[A].
  • Scalp abscesses (from scalp electrodes) (1,2 and 3)[A]
  • Asymptomatic infants born to mothers with untreated gonorrhea (1,2 and 3)[A]

Pregnancy Considerations

Pregnant women should be treated with cephalosporin or recommended alternative (1,2,3 and 4)[A].

  • Azithromycin 2 g orally in single dose for women intolerant to cephalosporin
  • Treat concurrently with azithromycin or amoxicillin for presumed C. trachomatis coinfection.
  • Women with 1st-trimester gonococcal infection should be retested within 3 to 6 months.
  • High-risk uninfected pregnant women should be retested during the 3rd trimester.

Second Line

  • Due to antimicrobial resistance, combination therapy using two agents with different mechanisms of action improves treatment efficacy and decreases resistance to cephalosporins (1,2 and 3)[A].Use of a second antimicrobial (azithromycin as a single 1-g oral dose or doxycycline 100 mg orally twice daily for 7 days) is recommended for use with ceftriaxone (1,2 and 3)[A].Azithromycin as the second antimicrobial is preferred to doxycycline because of convenience and compliance of single-dose therapy as well as higher resistance with tetracyclines (1,2 and 3)[A].
  • For additional treatment options, see CDC STD treatment guidelines: http://www.cdc.gov/std/tg2015/

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Hematogenously disseminated infection
  • Pneumonia or eye infection in infants
  • PID: if unable to take oral medications, significant tubo-ovarian abscess, or patient is pregnant

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

U.S. Preventive Services Task Force (USPSTF) (4)[A]

  • Screen all sexually active women, including those who are pregnant if they are at increased risk of infection (young or have other individual/population risk factor): Grade B recommendation
  • Insufficient evidence to recommend for or against screening men at increased risk of infection: Grade I recommendation
  • No routine screening in men and women who are low risk for infection: Grade D recommendation
  • Insufficient evidence to recommend for or against screening in pregnant women who are not at increased risk for infection: Grade I recommendation
  • Prophylactic ocular topical medication for all newborns: Grade A recommendation
  • Report cases of gonorrhea to public health authorities (3,4)[A]

PATIENT EDUCATION

  • Counseling concerning risk reduction, condom use, future fertility, and full STI testing
  • Encourage patient to notify partners (from past 60 days); consider EPT.

PROGNOSIS

Complete cure with return to normal function with adequate and timely treatment

COMPLICATIONS

  • Infertility
  • Urethral stricture
  • Corneal scarring
  • Destruction of joint articular surfaces
  • Cardiac valvular damage

Pediatric Considerations

Vertical transmission to newborn infants is a significant risk among patients with gonococcal infection at the time of delivery (1,2)[A].

REFERENCES

11 Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections. Am Fam Physician. 2012;86(10):931-938.22 Centers for Disease Control and Prevention. 2010 sexually transmitted diseases treatment guidelines: gonococcal infections. http://www.cdc.gov/std/treatment/2010/gonococcal-infections.htm33 Centers for Disease Control and Prevention. Update to CDCs sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococ-cal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594.44 U.S. Preventive Services Task Force. Chlamydia and Gonorrhea: Screening, September 2014. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and-gonorrhea-screening?ds=1&s=Gonorrhea

SEE ALSO

Chlamydia Infection (Sexually Transmitted); HIV/AIDS; Pelvic Inflammatory Disease; Syphilis

CODES

ICD10

  • A54.9 Gonococcal infection, unspecified
  • A54.31 Gonococcal conjunctivitis
  • A54.03 Gonococcal cervicitis, unspecified
  • A54.5 Gonococcal pharyngitis
  • A54.01 Gonococcal cystitis and urethritis, unspecified
  • A54.6 Gonococcal infection of anus and rectum

ICD9

  • 098.0 Gonococcal infection (acute) of lower genitourinary tract
  • 098.40 Gonococcal conjunctivitis (neonatorum)
  • 098.15 Gonococcal cervicitis (acute)
  • 098.6 Gonococcal infection of pharynx
  • 098.7 Gonococcal infection of anus and rectum

SNOMED

  • 15628003 Gonorrhea (disorder)
  • 28438004 gonococcal conjunctivitis neonatorum (disorder)
  • 237083000 Gonococcal cervicitis (disorder)
  • 74372003 Gonorrhea of pharynx (disorder)
  • 186931002 Gonococcal anal infection (disorder)
  • 236682002 Gonococcal urethritis (disorder)

CLINICAL PEARLS

  • Due to frequent coinfection, treatment for uncomplicated gonorrhea should include two drugs, one of which is effective against chlamydia.
  • Screen patients with gonorrhea for chlamydia, syphilis, HIV, and hepatitis.