| Treatment failure can lead to continued transmission and the emergence of antibiotic resistance. The importance of adequate treatment with a regimen that the patient will adhere to cannot be overemphasized. Thus highly effective single-dose regimens have been developed for uncomplicated gonococcal infections. The updated 2006 treatment guidelines for gonococcal infections from the Centers for Disease Control and Prevention are summarized in Table 137-1; the recommendations for uncomplicated gonorrhea apply to HIV-infected as well as HIV-uninfected patients.
Table 137-1 Recommended Treatment for Gonococcal Infections: 2006 Guidelines of the Centers for Disease Control and Prevention (Updated in 2007) |
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| Diagnosis | Treatment of Choice |
| Uncomplicated gonococcal infection of the cervix, urethra, pharynx, or rectuma |
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| First-line regimens | Ceftriaxone (125 mg IM, single dose) Cefixime (400 mg PO, single dose) Treatment for Chlamydia if chlamydial infection is not ruled out: Azithromycin (1 g PO, single dose) Doxycycline (100 mg PO bid for 7 days) |
| Alternative regimens | Ceftizoxime (500 mg IM, single dose) Cefotaxime (500 mg IM, single dose) Spectinomycin (2 g IM, single dose)b,c Cefotetan (1 g IM, single dose) plus probenecid (1 g PO, single dose)b Cefoxitin (2 g IM, single dose) plus probenecid (1 g PO, single dose)b |
| Epididymitis | See Chap. 124 |
| Pelvic inflammatory disease | See Chap. 124 |
| Gonococcal conjunctivitis in an adult | Ceftriaxone (1 g IM, single dose)d
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| Ophthalmia neonatorume
| Ceftriaxone (25–50 mg/kg IV, single dose, not to exceed 125 mg) |
| Disseminated gonococcal infectionf
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| Initial therapyg
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| Patient tolerant of -lactam drugs | Ceftriaxone (1 g IM or IV q24h; recommended) |
| Patients allergic to -lactam drugs | Spectinomycin (2 g IM q12h)c |
| Continuation therapy | |
| Meningitis or endocarditis | See texth
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aTrue failure of treatment with a recommended regimen is rare and should prompt an evaluation for reinfection or consideration of an alternative diagnosis. bSpectinomycin, cefotetan, and cefoxitin, which are alternative agents, currently are unavailable or in short supply in the United States. cSpectinomycin may be ineffective for the treatment of pharyngeal gonorrhea. dPlus lavage of the infected eye with saline solution (once). eProphylactic regimens are discussed in the text. fHospitalization is indicated if the diagnosis is uncertain, if the patient has frank arthritis with an effusion, or if the patient cannot be relied on to adhere to treatment. gAll initial regimens should be continued for 24–48 h after clinical improvement begins, at which time therapy may be switched to one of the continuation regimens to complete a full week of antimicrobial treatment. Treatment for chlamydial infection (as above) should be given if this infection has not been ruled out. hHospitalization is indicated to exclude suspected meningitis or endocarditis.
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Single-dose regimens of the third-generation cephalosporins ceftriaxone (given IM) and cefixime (given orally) are the mainstays of therapy for uncomplicated gonococcal infection of the urethra, cervix, rectum, or pharynx. Quinolone-containing regimens are no longer recommended in the United States as first-line treatment because of widespread resistance to these agents.
Because co-infection with C. trachomatis occurs frequently, initial treatment regimens must also incorporate an agent (e.g., azithromycin or doxycycline) that is effective against chlamydial infection. Pregnant women with gonorrhea, who should not take doxycycline, should receive concurrent treatment with a macrolide antibiotic for possible chlamydial infection. A single 1-g dose of azithromycin, which is effective therapy for uncomplicated chlamydial infections, results in an unacceptably low cure rate (93%) for gonococcal infections and should not be used alone. Spectinomycin has been an alternative regimen for the treatment of uncomplicated gonococcal infections in penicillin-allergic persons. However, spectinomycin is not available in the United States at this time. A single 2-g dose of azithromycin is effective against sensitive strains, but this drug is expensive, causes gastrointestinal distress, and is not recommended for routine or first-line treatment of gonorrhea.
Persons with uncomplicated infections who receive a recommended regimen do not need a test of cure. Cultures for N. gonorrhoeae should be performed if symptoms persist after therapy with an established regimen, and any gonococci isolated should be tested for antimicrobial susceptibility.
Symptomatic gonococcal pharyngitis is more difficult to eradicate than genital infection. Persons who cannot tolerate cephalosporins and those in whom quinolones are contraindicated may be treated with spectinomycin if it is available, but this agent results in a cure rate of 52%. Persons given spectinomycin should have a pharyngeal sample cultured 3–5 days after treatment as a test of cure. A single 2-g dose of azithromycin may be used in areas where rates of resistance to azithromycin are low.
Treatments for gonococcal epididymitis and PID are discussed in Chap. 124. Ocular gonococcal infections in older children and adults should be managed with a single dose of ceftriaxone combined with saline irrigation of the conjunctivae (both undertaken expeditiously), and patients should undergo a careful ophthalmologic evaluation that includes a slit-lamp examination.
DGI may require higher dosages and longer durations of therapy (Table 137-1). Hospitalization is indicated if the diagnosis is uncertain, if the patient has localized joint disease that requires aspiration, or if the patient cannot be relied on to comply with treatment. Open drainage is necessary only occasionally—e.g., for management of hip infections that may be difficult to drain percutaneously. Nonsteroidal anti-inflammatory agents may be indicated to alleviate pain and hasten improvement of affected joints. Gonococcal meningitis and endocarditis should be treated in the hospital with high-dose IV ceftriaxone (1–2 g every 12 h); therapy should continue for 10–14 days for meningitis and for at least 4 weeks for endocarditis. All persons who experience more than one episode of DGI should be evaluated for complement deficiency.
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| Prevention and Control
Condoms, if properly used, provide effective protection against the transmission and acquisition of gonorrhea as well as other infections that are transmitted to and from genital mucosal surfaces. Spermicidal preparations used with a diaphragm or cervical sponges impregnated with nonoxynol 9 offer some protection against gonorrhea and chlamydial infection. However, the frequent use of preparations that contain nonoxynol 9 is associated with mucosal disruption that paradoxically may enhance the risk of HIV infection in the event of exposure. All patients should be instructed to refer sex partners for evaluation and treatment. All sex partners of persons with gonorrhea should be evaluated and treated for N. gonorrhoeae and C. trachomatis infections if their last contact with the patient took place within 60 days before the onset of symptoms or the diagnosis of infection in the patient. If the patient's last sexual encounter was >60 days before onset of symptoms or diagnosis, the patient's most recent sex partner should be treated. Partner-delivered medications or prescriptions for medications to treat gonorrhea and chlamydial infection diminish the likelihood of reinfection (or relapse) in the infected patient. In states where it is legal, this approach is an option for partner management. Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms. Greater emphasis must be placed on prevention by public health education, individual patient counseling, and behavior modification. Sexually active persons, especially adolescents, should be offered screening for STIs. For males, a NAAT on urine or a urethral swab may be used for screening. Preventing the spread of gonorrhea may help reduce the transmission of HIV. No effective vaccine for gonorrhea is yet available, but efforts to test several candidates are under way.
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Harrison's Internal Medicine > Chapter 137. Gonococcal Infections
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