gonorrhea%20-%20uncomplicated%20anogenital%20infection
GONORRHEA - UNCOMPLICATED ANOGENITAL INFECTION
Gonorrhea is a sexually or vertically transmitted infection secondary to Gram-negative diplococcus Neisseria gonorrhoeae.
It is one of the most common bacterial sexually transmitted infections that may cause pelvic inflammatory disease leading to infertility or ectopic pregnancy.
Most of the infected females are asymptomatic but may present with increased or altered vaginal discharge, dysuria, urethral discharge, abnormal vaginal bleeding, vulval itching or burning, dyspareunia, conjunctivitis and proctitis.

Follow Up

  • Helpful to confirm compliance of patient with the treatment, ensure resolution of symptoms, inquire about possibility of re-infection, adverse reaction to treatment, or treatment failure and drug resistance, and check on partner notification
  • Some authorities have recommended that test of cure should be done in all patients with gonococcal infection giving priority to those with persistent signs or symptoms after the treatment and those patients treated with alternative regimens with unknown antimicrobial susceptibility
    • Test-of-cure should be done 1 week after completion of treatment
      • Others have recommended test of cure to be done 72 hours after completion of therapy in patients with persistent signs and symptoms or 2 weeks after in asymptomatic patients
      • Ideally performed with culture or, if not available, with NAAT (2 weeks after treatment) for N gonorrhoeae
        • Confirmatory culture should be done if NAAT’s result is positive; if culture is positive, phenotypic antimicrobial susceptibility testing should be performed
  • Pregnant women should be retested 3 months after therapy and during the 3rd trimester if risk for gonococcal infection is high  
  • Culture of relevant specimens and susceptibility testing of N gonorrhoeae should be done in patients who have failed with the recommended treatment regimen and re-treat according to susceptibility results
  • If treatment failure happened after single therapy, re-treat with dual therapy; if treatment failure happened after dual therapy, re-treat with a dual therapy of higher dose
  • Patients who had treatment failure with alternative regimens should be treated with Ceftriaxone and Azithromycin and be referred to an infectious disease specialist for further management
  • Due to the emerging resistance to extended-spectrum cephalosporins in N gonorrhoeae, criteria for probable gonorrhea treatment failure include the following:  
    • Patient with laboratory-confirmed N gonorrhoeae infection and treated with cephalosporin-based regimen and subsequently tested positive for N gonorrhoeae (culture positive ≥72 hours after treatment or NAAT positive ≥7 days after treatment) and without sexual activity following treatment and
    • Pre- or post-treatment antimicrobial susceptibility testing of N gonorrhoeae isolates showed Ceftriaxone MIC ≥0.125 mcg/mL or Cefixime MIC ≥0.25 mcg/mL
  • Infections identified after treatment
    • Typically are due to reinfection which should be distinguished from treatment failure prior to retreatment  
      • Reinfected patients are re-treated with the recommended regimen, sexual abstinence or condom use is reinforced and partner is treated 
    • There may be a need for improved patient education and referral of sex partners

HIV/STI Testing and Counseling

  • Sexually transmitted infection (STI) consultation allows for an opportunity to discuss patient’s risk factors for STIs and human immunodeficiency virus (HIV)
  • Determine patient’s risk for HIV and discuss HIV testing
  • Testing for HIV is recommended and should be offered to all persons seeking evaluation and treatment for STIs
    • Pretest and post-test counseling, as well as informed consent, are part of the testing procedure
    • Concomitant infection with HIV may complicate management and control of some STIs
      • Treatment of gonococcal infection in patients with HIV is similar to patients who are HIV-negative
    • Gonococcal infection aids in transmission and increases susceptibility to HIV

Evaluation and Treatment of Sex Partners

  • Sex partners of STI patients may be asymptomatic, thus the importance for partner notification and management 
  • Sex partners of STI patients are likely to be infected and should be offered treatment to prevent further STI transmission and reinfection
  • All partners who had sexual contact with the patient within 60 days of the diagnosis of infection should be evaluated and treated for both gonococcal and chlamydial infection
    • If patient’s previous sexual intercourse was >60 days before diagnosis, the latest sexual partner should be evaluated and treated
  • For patients who present within 14 days of exposure, it is recommended to give epidemiological treatment; for those who present after 14 days of exposure, treat based on testing results 
  • Patients and their sex partners should be instructed to abstain from sexual intercourse until they and their partners have completed the treatment
    • Continue abstinence x 7 days after a single-dose regimen or until the completion of a 7-day regimen
Partner-delivered Therapy
  • In situations where concerns exist that the sex partners of a female patient with gonorrhea will not seek treatment, the patient may be the one to deliver therapy to their partners in the form of medication or a prescription
  • Partner-delivered therapy for gonorrhea should always include treatment for Chlamydia
  • The approach may not be permitted in some settings
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