Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 33-26: Gonococcal Infections + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Purulent, profuse urethral discharge with dysuria, especially in men; yields positive gram-stained smear In men Epididymitis Prostatitis Periurethral inflammation Proctitis Pharyngitis In women Asymptomatic or cervicitis with purulent discharge Vaginitis, salpingitis, proctitis also occur Disseminated disease Fever Rash Tenosynovitis Septic arthritis Nucleic acid amplification is preferred diagnostic test +++ General Considerations ++ Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus +++ Demographics ++ Gonorrhea is transmitted as a result of sexual activity; greatest incidence is in the 15- to 29-year-old age group + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Asymptomatic infection is common and occurs in both sexes Atypical sites of primary infection (eg, the pharynx or rectum) must always be considered +++ Urethritis ++ In men Initially, burning on urination and a serous or milky discharge One to 3 days later, more pronounced urethral pain and the discharge becomes yellow, creamy, and profuse, sometimes blood tinged May regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation Rectal infection is common in men who have sex with men In women Dysuria Urinary frequency and urgency +++ Cervicitis ++ Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination Infection often becomes symptomatic during menses Vaginitis and cervicitis with purulent discharge and inflammation of Bartholin glands are common Infection may remain as a chronic cervicitis It may progress to involve the uterus and fallopian tubes with acute and chronic salpingitis and ultimate scarring of tubes and sterility In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci +++ Conjunctivitis ++ Direct inoculation of gonococci into the conjunctival sac occurs by autoinoculation from a genital infection or during childbirth The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly +++ Differential Diagnosis ++ Nongonococcal urethritis, eg, Chlamydia, Ureaplasma urealyticum Septic arthritis of other bacterial cause Reactive arthritis Vaginal discharge due to candidiasis, bacterial vaginosis, or trichomoniasis Chronic meningococcemia + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ In men, Gram stain of urethral or rectal discharge, especially during the first week after onset, typically shows gram-negative diplococci within polymorphonuclear leukocytes Gram stain is less often positive in women Nucleic acid amplification tests The preferred testing method for diagnosing all types of gonococcal infection due to its excellent sensitivity and specificity Detects N gonorrhoeae in endocervical, vaginal, and urethral swab specimens and in urine Can also detect N gonorrhoeae in oropharyngeal and rectal sites, although test is not FDA approved for these specimen types Have largely replaced culture Cultures should still be obtained when evaluating a treatment failure to assess for antimicrobial resistance + Treatment Download Section PDF Listen +++ +++ Medications ++ For uncomplicated infections of cervix, urethra, or rectum Treatment of choice is ceftriaxone (250 mg intramuscularly) plus azithromycin (1000 mg orally as a single dose) When an oral cephalosporin is the only option, cefixime, 400 mg orally as a single dose, can be combined with azithromycin as above but a "test of cure" culture or nuclear amplification test is recommend 1 week after treatment When azithromycin is not an option, doxycycline at 100 mg orally twice daily for 7 days can be substituted Spectinomycin, 1 g intramuscularly once, may be used for the penicillin-allergic patient (not currently available in the United States) Fluoroquinolones are not recommended due to high rates of microbial resistance Pharyngeal gonorrhea also treated with ceftriaxone (250 mg intramuscularly) plus azithromycin (1000 mg orally as a single dose) Conjunctival gonorrhea is treated with ceftriaxone (1 g intramuscularly) plus azithromycin (1000 mg orally as a single dose) Pelvic inflammatory disease Cefoxitin, 2 g parenterally every 6 hours, or cefotetan, 2 g intravenously every 12 hours plus doxycycline 100 mg every 12 hours Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin, administered intravenously as a 2-mg/kg loading dose followed by 1.5 mg/kg every 8 hours Ceftriaxone, 250 mg intramuscularly as a single dose (or cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally as a single dose,) plus doxycycline, 100 mg twice a day for 14 days, with or without metronidazole, 500 mg twice daily for 14 days, is an effective outpatient regimen Disseminated gonococcal infection (including arthritis and arthritis-dermatitis syndromes) Ceftriaxone (1 g intravenously daily) plus azithromycin (1000 mg orally as a single dose), until 48 hours after improvement begins, at which time therapy may be switched to cefixime (400 mg orally daily) to complete at least 1 week of antimicrobial therapy Endocarditis Ceftriaxone, 2 g every 24 hours intravenously, for at least 4 weeks +++ Therapeutic Procedures ++ Therapy typically is administered before antimicrobial susceptibilities are known All sexual partners should be treated + Outcome Download Section PDF Listen +++ +++ Complications +++ Disseminated disease ++ Systemic complications follow the dissemination of gonococci from the primary site via the bloodstream Skin lesions Can range from maculopapular to pustular or hemorrhagic Tend to be few in number and peripherally located Tenosynovitis is often found in the hands and wrists and feet and ankles Arthritis can occur in one or more joints and may be migratory +++ Prevention ++ The condom, if properly used, can reduce the risk of infection Early treatment of contacts can halt the development of symptoms +++ When to Refer ++ Report all cases to the public health department for tracing of contacts +++ When to Admit ++ Most cases of pelvic inflammatory disease (perhaps not the mild cases) All cases of suspected or proven disseminated disease + References Download Section PDF Listen +++ + +De Ambrogi M. International forum on gonococcal infections and resistance. Lancet Infect Dis. 2017 Nov;17(11):1127. [PubMed: 29115267] + +Workowski KA et al; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1–137. [PubMed: 26042815]