Gonococcal infection in adolescents and adults

In the United States, new cases of N. gonorrhoeae infection are estimated to be 600,000 per year. Most men become symptomatic, prompting them to seek treatment quickly enough to prevent serious complications but not quickly enough to prevent transmission. Women are usually asymptomatic until complications such as PID develop. PID, with or without symptoms, can lead to tubal obstruction, which can lead to infertility or ectopic pregnancy. Because gonococcal infection is often asymptomatic in women, the primary gonorrhea control measure in the United States is screening of women at high risk.

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Uncomplicated gonococcal infection

Recommended schemes

• Cefixime 400 mg orally, single dose,
• or Ceftriaxone 125 mg intramuscularly once,
• or Ciprofloxacin 500 mg orally once,
• or Ofloxacin 400 mg orally once,
• plus Azithromycin 1 g orally once
• or Doxycycline 100 mg orally 2 times a day for 7 days.

The spectrum of antimicrobial action of cefixime is similar to that of ceftriaxone, but an oral dose of 400 mg of cefixime does not provide such a constant and high bactericidal level of the drug in the blood as 125 mg of ceftriaxone. Published data from clinical studies have shown that a dose of 400 mg cures 97.1% of uncomplicated urogenital and anorectal infections. An advantage of cefixime is that it can be used orally.

A single dose of ceftriaxone 125 mg provides a constant high bactericidal level of the drug in the blood. Extensive clinical experience shows that it is safe and effective for the treatment of uncomplicated gonorrhea and cures 99.1% of cases of uncomplicated urogenital and anorectal infection according to clinical trials.

Ciprofloxacin is highly active against most strains of N. gonorrhoeae and at a dose of 500 mg provides a constant bactericidal level in the blood, curing 99.8% of uncomplicated urogenital and anorectal infections in published clinical trials. Ciprofloxacin is safe, relatively inexpensive, and can be administered orally.

Ofloxacin is also very active against most strains of N. gonorrhoeae and has favorable pharmacokinetics. An oral dose of 400 mg effectively cures uncomplicated urogenital and anorectal infections in 98.4% of cases.

Uncomplicated gonococcal infection of the larynx

Gonococcal infection of the larynx is much more difficult to cure than infection of the urogenital and anogenital areas. Several recommended treatment regimens are effective in more than 90% of cases.

Recommended schemes

• Ceftriaxone 125 mg intramuscularly once,
• or Ciprofloxacin 500 mg orally once,
• or Ofloxacin 400 mg orally once,
• plus Azithromycin 1 g orally once
• or Doxycycline 100 mg orally 2 times a day for 7 days.

Gonococcal conjunctivitis

In recent years, only one study has been published on the treatment of gonococcal conjunctivitis in adults, conducted in North America. This study showed good results with ceftriaxone 1 g IM in 12 of 12 patients.

Treatment

A single dose of 1 g ceftriaxone should be administered intramuscularly; in addition, the affected eye is washed once with saline solution.

Management of sexual partners

Patients should be instructed to notify sexual partners of the need for testing and treatment (see Uncomplicated Gonococcal Infection, Management of Sexual Partners).

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Disseminated gonococcal infection

Disseminated gonococcal infection (DGI) results from gonococcal bacteremia, often manifesting as petechial or pustular lesions, asymmetric arthralgias, tenosynovitis, or septic arthritis. Occasionally, the infection is complicated by perihepatitis and, rarely, endocarditis or meningitis. Strains of N. gonorrhoeae that cause disseminated gonococcal infection tend to produce mild inflammation in the genital area. Such strains have rarely been isolated in the United States in the past decade.

There have been no recent published data on the treatment of disseminated gonococcal infection in North America.

Treatment

Hospitalization is recommended for initial therapy, especially when there is uncertainty about whether the patient will complete the full course of treatment, or when the diagnosis is unclear or there is purulent joint effusion or other complications. Patients should be evaluated for endocarditis and meningitis. Patients treated for disseminated gonococcal infection should also be treated prophylactically for chlamydial infection.

Recommended Starting Scheme

Ceftriaxone 1 g IM or IV every 24 hours.

Alternative Initial Schemes

Ceftriaxone 1 g IV every 8 hours,

Or Ceftizoxime 1 g IV every 8 hours,

Or For people with allergies to beta-lactam drugs:

Ciprofloxacin 500 mg IV every 12 hours

Or Ofloxacin 400 mg IV every 12 hours

Or Spectinomycin 2 g IM every 12 hours.

Treatment according to all these regimens should be continued for 24-48 hours after the onset of improvement; then treatment can be carried out according to one of the following regimens (total duration of treatment is 1 week):

Cefixime 400 mg orally twice daily,

Or Ciprofloxacin 500 mg orally 2 times a day.

Or Ofloxacin 400 mg orally 2 times a day

Management of sexual partners

Gonococcal infection in sexual partners of persons with disseminated gonococcal infection is often asymptomatic. As with uncomplicated infection, patients should be instructed to notify sexual partners and to refer them for evaluation and treatment (see Uncomplicated Gonococcal Infection, Management of Sexual Partners).

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Gonococcal meningitis and endocarditis

Recommended Starting Scheme

Ceftriaxone 1-2 g IV every 12 hours.

Treatment of meningitis should continue for 10-14 days, and endocarditis for at least 4 weeks. Treatment of complicated DGI should be carried out with the participation of experts.

Management of sexual partners

As with uncomplicated infection, patients should be instructed to notify sexual partners and bring them in for evaluation and treatment.

Concomitant treatment of gonorrhea and chlamydial infection

Because C. trachomatis is frequently found in persons infected with N. gonorrhoeae, patients treated for gonorrhea should also be treated with drugs effective against uncomplicated genital chlamydial infection. In populations where chlamydial infection is coexistent with gonococcal infection in 20% to 40% of cases, providing therapy against both pathogens without prior chlamydial testing may be advantageous because treatment for chlamydia is significantly less expensive ($0.50 to $1.50 for doxycycline) than testing. Some experts believe that routine use of such therapy would significantly reduce the prevalence of chlamydial infection. Because most gonococcal strains in the United States are susceptible to doxycycline and azithromycin, their concomitant use may prevent the development of antimicrobial resistance in N. gonorrhoeae.

Since the introduction of dual therapy, the prevalence of chlamydial infection has decreased in some populations, and chlamydial testing has become more sensitive and more widely used. Where the prevalence of co-infection is low, some clinicians may choose to test for chlamydia rather than administer combination therapy. However, this treatment is indicated for patients who may not return for test results.

Resistance of N. gonorrhoeae to quinolones

Quinolone-resistant gonorrhea has occurred sporadically in many parts of the world, including North America, and is becoming widespread in Asian regions. By February 1997, quinolone-resistant gonococci were still rare in the United States. Less than 0.05% of 4,639 isolates collected by the Gonococcal Strain Surveillance Program (GISP) in 1996 had a minimum inhibitory concentration (MIC) to ciprofloxacin >1.0 mg/mL. The isolates were obtained from 26 cities and represented approximately 1.3% of all isolates from men diagnosed with gonococcal infection in the United States. Because quinolone-resistant strains account for less than 1% of all N. gonorrhoeae strains isolated in each of the 26 cities, fluoroquinolones can be recommended for use. However, gonococcal resistance to quinolones is likely to increase.

Alternative schemes

Spectinomycin 2 g IM once. Spectinomycin is expensive and must be given by injection. However, it is an effective drug and, according to published clinical trials, cures 2% of cases of uncomplicated urogenital and anorectal infections. Spectinomycin remains the drug of choice for patients who are intolerant of both cephalosporins and quinolones.

Single-dose cephalosporin regimens that are effective for uncomplicated genital or anal gonorrhea, other than ceftriaxone (125 mg IM) and cefixime (400 mg orally), include (a) ceftizoxime 500 mg IM as a single dose, (b) cefotaxime 500 mg IM as a single dose, (c) cefotetan 1 g IM as a single dose, and (d) cefoxitin 1 g IM as a single dose with probenecid 1 g orally. None of these injectable cephalosporins offers any advantages over ceftriaxone, and there is less clinical experience with their use in uncomplicated gonorrhea.

Single-dose quinolone regimens include enoxacin 400 mg orally; lomefloxacin 400 mg orally; and norfloxacin 800 mg orally. They have been shown to be safe and effective in the treatment of uncomplicated gonorrhea but do not offer any advantage over ciprofloxacin 500 mg or ofloxacin 400 mg.

There are many other antimicrobial agents that have activity against N. gonorrhoeae, but it is beyond the scope of this guideline to list all effective treatment regimens.

Azithromycin, 2 g orally, is effective against uncomplicated gonococcal infection, but is expensive and causes too much gastrointestinal upset to be recommended for the treatment of gonorrhea. At a dose of 1 g orally, azithromycin is not very effective, curing only 93% of cases in published studies.

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Follow-up observation

Persons with uncomplicated gonorrhea treated with any of the regimens recommended in this guideline do not require monitoring of cure. If symptoms persist after completion of treatment, N. gonorrhoeae culture should be performed to determine the antimicrobial resistance of all isolated gonococcal strains. Infections detected after treatment with one of the recommended regimens usually result from reinfection rather than treatment failure, indicating the need for improved partner notification and patient education. Chronic urethritis, cervicitis, or proctitis may also be caused by C. trachomatis or other organisms.

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Management of sexual partners

Patients should be instructed to notify their sexual partners and to involve them in testing and treatment. All sexual partners of patients with gonorrhea should be tested and treated for gonorrhea and chlamydia if the last sexual contact occurred within 60 days of the patient's symptom onset or diagnosis. If the patient's last sexual contact occurred more than 60 days before the patient's symptom onset or diagnosis, the patient's last sexual partner should be treated. Patients should be instructed to abstain from sexual contact until treatment is completed and the patient and partner(s) are asymptomatic.

Special Notes

Allergy, intolerance or side effects

Patients who are intolerant to cephalosporins and quinolones should be treated with spectinomycin. However, since spectinomycin has been shown to be effective in treating pharyngeal infection in only 52% of cases, patients with suspected or known pharyngeal infection should undergo pharyngeal culture 3-5 days after treatment to confirm clearance of the pathogen.

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Pregnancy

Pregnant women should not receive quinolones or tetracyclines. Pregnant women infected with N. gonorrhoeae should be treated with cephalosporins according to the recommended or alternative regimens. For women intolerant to cephalosporins, a single IM dose of 2 g of spectinomycin is recommended.

Erythromycin or amoxicillin are the drugs of choice if chlamydial infection is suspected or diagnosed during pregnancy (see Chlamydial infection).

HIV infection

People with HIV infection and gonococcal infection should receive the same treatment as patients without HIV infection.