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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.