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Hot Topics in Sexually Transmitted Infections and Associated Conditions

(Published November 2013)

Gonorrhea

  • Key facts about infection
    • Gonorrhea, or gonococcal infection, is the second most common reportable infection in the United States, with 321,849 cases reported in 2011, although the actual number of cases is estimated to approximate 600,000.9,13
    • Almost all men with urethral gonorrhea (> 95 percent) are symptomatic, typically with prominent urethral discharge and often dysuria. However, infection is disproportionately transmitted by the minority who are without symptoms, who ignore symptoms, or whose symptoms begin after transmission.9
    • In contrast, women may develop urethritis or cervicitis but often are asymptomatic until PID or other complications have developed.9
    • Chlamydial co-infection is present in 20 to 40 percent of patients with GC.14,15
    • Drug resistance in N. gonorrhoeae is a growing problem.16
  • Screening and diagnosis
    • No official criteria for GC screening have been proposed.
    • CDC does not recommend widespread screening of asymptomatic women; however, targeted screening of women ages  25 years with risk factors is suggested.
    • Risk factors for GC recognized by the United States Prevention Services Task Force (USPSTF) include the following:17
        • History of GC infection
        • Other STIs
        • New sex partner
        • Multiple sex partners
        • Inconsistent condom use
        • Transactional sex
    • Testing options

Table 5: Testing Options for Gonorrhea9,16

NAAT Culture
Higher sensitivity than culture—the usual test of choice Preserves isolate for potential antimicrobial sensitivity testing¡ªuseful for evaluating and managing suspected
treatment failure
Allows the widest variety of testing sites, but specific test kits vary in the specimen types for which they are FDA cleared Used to assess trends in antimicrobial susceptibility
    • Anatomical sites for testing
        • In women
          • Vaginal swab is the preferred site for NAAT screening and may be collected by either clinician or patient.
          • Endocervical swab is an acceptable alternative source for NAAT for either gonorrhea or chlamydia.
          • A urine specimen (first catch rather than midstream clean catch) is acceptable for screening when vaginal or endocervical testing are impractical (e.g., in nonclinical settings).
          • Specimens from the pharynx and rectum should be tested if sexual exposure has occurred.
        • In men
          • Either a first-catch urine specimen or a urethral swab can be used for testing.
          • Specimens from the pharynx and rectum should be tested if sexual exposure has occurred.
    • NAATs are not FDA cleared for nongenital sites such as the pharynx, although some laboratories have created performance specifications that allow NAATs to be used for these sites. Clinicians should check product inserts or check with their laboratories for specific information.
    • Laboratories may require different types of swabs for different collection sites (e.g., vaginal, male urethral, oropharyngeal) for NAATs. Clinicians should ensure use of the correct collection kits.
  • Treatment and management

Table 6: Recommended Regimens for Treatment of Uncomplicated Genital or Oropharyngeal Gonorrhea Infection in Adults*9

Medication Dosage Comments
Ceftriaxone PLUS 250 mg intramuscular, single dose All patients should receive dual therapy with ceftriaxone plus either azithromycin or doxycycline, whether or not CT co-infection is documented or suspected
Azithromycin 1 g orally, single dose
Ceftriaxone PLUS 250 mg intramuscular, single dose  
Doxycycline 100 mg orally twice daily for 7 days Contraindicated in pregnancy
For severe cephalosporin allergy
Azithromycin 2 g orally, single dose Perform test of cure at 1 week**

* For alternative regimens or for treatment of children or individuals with complicated infection, coexisting HIV infection, or infection at other sites, see CDC treatment guidelines and update.

** NAAT may remain positive for up to three weeks despite successful treatment; for earlier test-of-cure, culture is recommended.

    • Treatment is recommended for all sex partners within the preceding 60 days. EPT is a routine option when the partner may not seek clinical treatment and where allowed by local/state regulations.
    • Clinicians should report cases of confirmed gonorrhea to the local or state health department as required by law.
    • Drug-resistant GC
        • Because of increasing resistance of GC, CDC no longer recommends cefixime at any dose as a first-line regimen for treatment of confirmed gonorrhea. However, cefixime plus azithromycin remains the recommended regimen for EPT.16
        • If a clinician suspects treatment failure due to antimicrobial resistance, cultures of relevant clinical specimens with antimicrobial susceptibility testing should be requested.
        • Following apparent treatment failure, most patients will respond to repeat treatment with ceftriaxone plus azithromycin or doxycycline. However, clinicians also should consult an infectious disease specialist, a STD/HIV Prevention Training Center consultant (www.nnptc.org), or CDC (telephone: (404) 639-8659).
        • Report all drug-resistant cases to the local or state health department within 24 hours of diagnosis.
        • Following suspected treatment failure, ensure that all the patient's sex partners from the preceding 60 days are evaluated (with culture, in addition to NAAT, with antimicrobial sensitivity testing if culture is positive) and treated with ceftriaxone (unless a severe cephalosporin allergy is suspected) plus azithromycin or doxycycline.