Gonorrhea%20-%20uncomplicated%20anogenital%20infection Treatment

Syndromic Management

• 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

• 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

• 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 further information

• 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 

• Ceftriaxone
  • Considered as the most effective treatment for uncomplicated gonorrhea, in combination with a single oral 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 
  • May be considered in pregnant women only if other drug alternatives are unavailable and if isolate is determined to be susceptible

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
• When quinolone resistance has been excluded, these may be given as alternative agents in patients with cephalosporin allergy or penicillin anaphylaxis

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 or resistance)
  • Adverse effects are mostly gastrointestinal
• Other therapeutic agents currently being investigated for gonorrhea treatment include Ertapenem, Solithromycin, Zoliflodacin, Gepotidacin, Delafloxacin, Sitafloxacin and Avarofloxacin