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.

Pharmacotherapy

Syndromic Management

In areas where resources allow for lab tests to screen women
  • Empiric therapy should be considered when:
    • Prevalence of N gonorrhoeae and C trachomatis is high in the patient population and the patient is unlikely to return for treatment
In areas where lab tests to screen women are not available
  • The justification for empiric treatment becomes stronger as the prevalence of gonorrheal and chlamydial infections in the patient population becomes higher
    • Patients with positive risk assessment and vaginal discharge should be offered treatment for gonococcal and chlamydial cervicitis
Dual therapy for N gonorrhoeae and C trachomatis is recommended because patients infected with N gonorrhoeae are often co-infected with C trachomatis
  • Routine dual therapy can be cost-effective for populations in which chlamydial infection accompanies 10-30% of gonococcal infections because the cost of therapy for chlamydial infection is less than the cost of testing
  • A specific diagnosis may enhance partner notification, improve compliance with treatment, and decrease antibiotic exposure and expense
  • If the proper diagnostic tools are not available, patients should be treated for both infections
  • Please see Chlamydia-Uncomplicated Anogenital Infection Disease Management Chart for treatment details
Treatment for Uncomplicated Anogenital N gonorrhoeae Infection
  • Treatment with the most effective agents will reduce gonorrhea infection transmission, prevent complications, and will probably slow down emergence of antimicrobial resistance
  • Information about sexual behavior and recent travel history are important to ensure suitability of treatment given
  • Directly observed, single-dose therapy for N gonorrhoeae is recommended to enhance compliance
  • Antimicrobial therapy should consider local patterns of antimicrobial sensitivity to N gonorrhoeae
    • Many gonococcal isolates are now resistant to sulfonamides, penicillins, tetracyclines and quinolones
    • If local resistance data are unavailable, dual therapy is suggested over single therapy for treatment of genital gonorrhea
      • Dual therapy is also recommended due to the emerging resistance to cephalosporins and the lack of alternative 1st-line agents 
Cephalosporins
  • Ceftriaxone
    • Considered as the most effective treatment for uncomplicated gonorrhea, in combination with a single dose of Azithromycin or 7-day regimen of Doxycycline
      • Doxycycline is used in patients allergic to or intolerant of Azithromycin 
    • May also be given in pregnant patients except for Doxycycline 
    • Studies have shown that single intramuscular (IM) injection of 250-mg dose provides high and maintained bactericidal levels in the blood
    • Effective treatment for N gonorrhoeae infections at all sites
  • Cefixime
    • Currently not recommended as a 1st-line treatment option for patients with gonococcal infections due to evidences that showed increased minimum inhibitory concentrations that may predict emergence of N gonorrhoeae resistance
      • Studies have shown that 400-mg single oral dose does not provide sustained and high bactericidal levels as compared to single IM dose of Ceftriaxone
      • Also showed limited effectiveness in treating pharyngeal gonorrhea
    • May be given as an alternative agent if Ceftriaxone is not available or if patient refused or has contraindications to IM injection
      • Patient should be advised to return for a test-of-cure at the site of infection after 1 week
  • Alternative agents: Single-dose cephalosporins (Cefotaxime, Ceftizoxime, Cefoxitin with Probenecid or Cefpodoxime)
    • Have no advantage over Ceftriaxone or Cefixime in terms of efficacy or pharmacokinetics

Spectinomycin

  • May be used as an alternative regimen in combination with a single oral dose of Azithromycin in patients allergic to cephalosporins or in patients who are pregnant

Macrolides

  • Azithromycin
    • Preferred 2nd antimicrobial agent in addition to Ceftriaxone irrespective of Chlamydia testing results
      • Better than Doxycycline due to its convenience and increased compliance of single-dose therapy, and lower prevalence of gonococcal resistance
      • May be an option in persons known to have severe allergy to cephalosporins; however, monotherapy for gonorrhea treatment is not recommended due to increasing gonococcal resistance 

Quinolones

  • No longer recommended for gonorrhea treatment in many areas due to increasing resistance rate
  • Quinolone-resistant N gonorrhoeae (QRNG) is common in parts of Europe, US, Middle East, Asia and the Pacific
  • There are variations in the anti-gonococcal activity of individual quinolones and it is necessary to use only the most active according to local resistance patterns
  • May be used in areas where prevalence of resistance is <5%
    • May be given if an infection is known as quinolone-sensitive prior to treatment

Other Treatment Regimens

  • Injectable Gentamicin or oral Gamifloxacin combined with oral Azithromycin are new antibiotic regimens which have shown high rates of effectivity in treating genital gonorrhea
    • May be considered an option when Ceftriaxone cannot be given (eg severe allergic reaction)
    • Adverse effects are mostly gastrointestinal
  • Other therapeutic agents currently being investigated for gonorrhea treatment include Ertapenem, Solithromycin, Zoliflodacin, Gepotidacin, Delafloxacin, Sitafloxacin and Avarofloxacin 
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