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{{Gonorrhea}}
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{{CMG}}; {{AE}} {{Saram}}
{{CMG}}; {{AE}} {{SaraM}} {{nuha}}


==Overview==
==Overview==
The mainstay of therapy for gonococcal infections is antimicrobial therapy.  Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials, therefore a combination therapy with [[Azithromycin]] and a [[Cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance.
The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].  Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to [[antimicrobials]]; accordingly, [[Ceftriaxone]] is standard of care for treatment of gonorrhea. Routinely combining [[ceftriaxone]] with [[azithromycin]] for treatment of gonorrhea is no longer recommended.


==Medical Therapy==
==Medical Therapy==
*The mainstay of therapy for gonococcal infections is antimicrobial therapy.
*Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to antimicrobials, therefore a combination therapy with [[Azithromycin]] and a [[Cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance. 
*[[Ceftriaxone]] and [[cefixime]] exist as the last remaining options for empirical first-line treatment of ''[[Neisseria gonorrhoeae]]''<ref name=CDC-Guidline> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>


{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
*The mainstay of therapy for gonococcal infections is [[antimicrobial|antimicrobial therapy]].<ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR2">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 &#124; MMWR |format= |work= |accessdate=}}</ref>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
|+
|+
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 200px;" |{{fontcolor|#FFF|Type of gonococcal infection}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Regimen}}
! style="background: #4479BA; width: 450px;" |{{fontcolor|#FFF|Regimen}}
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Uncomplicated Recommended regimen'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |<br />
*[[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose  
 
*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
 
*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
*[[Chlamydial]] co-infection:
**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated Alternative regimen'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Gentamicin]] 240 mg IM as a single dose plus [[azithromycin]] 2 g PO as a single dose OR
*Test of cure should be performed after 1 week
 
*[[Cefixime]] 800 mg PO as a single dose.
 
(Add [[doxycycline]] 100 mg PO BID for 7 days if [[Chlamydia infection|chlamydial]] infection has not been excluded)
 
(During [[pregnancy]], [[azithromycin]] 1 g as a single dose is recommended to treat chlamydia).
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Alternative regimens for severe Cephalosporin allergy'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available'''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
*[[Ceftriaxone]] is not available:
*[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
**[[cefixime]] 800 mg PO OD if the other injectable [[cephalosporin]] not available.
*Severe Cephalosporin allergy
**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
*Test of cure should be performed after 1 week
*Test of cure should be performed after 1 week
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Arthritis and arthritis-dermatitis syndrome '''
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Ceftriaxone]] 1 g IM/IV q24h for 7 days
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Cefotaxime]] 1 g IV q8h for 7 days (alternative)
*[[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose (alternative)
*[[Ceftizoxime]] 1 g IV q8h  for 7 days
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #DCDCDC;" |'''Gonococcal meningitis and endocarditis'''
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days
|}
|}


==Drug Resistance==
*High-level resistance to these expanded-spectrum [[cephalosporins]] is now reported, and it seems developing another effective treatment has become unaffordable.
*Although new combination antibiotic treatments are being evaluated. There are no affordable alternative therapeutic options currently available for the treatment of gonococcal disease. and it seems even newly developed antibiotics will be short solution and may be developed resistance as well.
The drug resistance may be developed by following mechanisms:
*Chromosomal mutations
*Acquisition of R factors ([[plasmids]])
[[Image:Drug_in_Gonorrhea.jpg|500px|thumb|center]]
===Antimicrobial Regimen===
===Antimicrobial Regimen===
:* '''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
 
::* 1. '''Gonococcal infections in adolescents and adults'''
:*'''Neisseria gonorrhoeae treatment'''<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref><ref name="urlUpdate to CDCs Treatment Guidelines for Gonococcal Infection, 2020 | MMWR">{{cite web |url=https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#B1_down |title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 &#124; MMWR |format= |work= |accessdate=}}</ref><ref name="urlGonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm |title=Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines |format= |work= |accessdate=}}</ref>
:::* 1.1 '''Uncomplicated gonococcal infections of the cervix, urethra, and rectum'''
::*1. '''Gonococcal infections in adolescents and adults'''
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::*1.1 '''Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.'''
::::* Alternative regimen: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose (if ceftriaxone is not available)
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
:::* 1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::*[[Chlamydial]] co-infection:
:::::* 1.2.1 '''Management of sex partners'''
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
::::::* Expedited partner therapy: [[Cefixime]] 400 mg PO in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::*1.2 '''Uncomplicated gonococcal infections of the pharynx'''
::::::* Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.  
::::*pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
::::::* Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::*[[Ceftriaxone]] 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
::::::* Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
::::*[[ceftriaxone]] 1 g IM, for persons weighing ≥150 kg (300 lb).
:::::* 1.2.2  '''Allergy, intolerance, and adverse reactions'''
::::*[[Chlamydial]] co-infection:
::::::* Preferred regimen (1): [[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::**add [[doxycycline]] 100 mg PO BID 7 days. (In pregnancy [[azithromycin]] 1 g as a single dose)
::::::* Preferred regimen (2): [[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
::::**No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
::::::* Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::::*1.2.1 '''Management of sex partners'''
:::::* 1.2.3 '''Pregnancy'''
::::::*Expedited partner therapy: oral [[cefixime]] 800 mg orally once plus treatment for [[chlamydia]] is used for treatment of the partner.<ref name="pmid33332296">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296  }}</ref>
::::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
:::::* 1.2.4 '''Suspected cephalosporin treatment failure'''
::::::*Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
::::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
::::::* Alternative regimen (1): [[Gemifloxacin]] 320 mg PO  single dose  {{and}} [[Azithromycin]] 2 g PO  single dose (when isolates have elevated cephalosporin MICs)
::::::*Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
::::::* Alternative regimen (2): [[Gentamicin]] 240 mg IM single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
:::::*1.2.2  '''Allergy, intolerance, and adverse reactions'''
::::::* Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
::::::*[[Ceftriaxone]] is not available:
::::::* Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
::::::**A different injectable [[cephalosporin]] like [[ceftizoxime]] [500 mg IM], [[cefoxitin]] [2 g IM with [[probenecid]] 1 g PO], or [[cefotaxime]] [500 mg IM]) can be used.
:::* 1.3 '''Gonococcal conjunctivitis'''
::::::**[[cefixime]] 800 mg orally once can be used for gonococcal therapy if the other injectable [[cephalosporin]] not available.
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Severe Cephalosporin allergy:
::::: Note: Consider one-time lavage of the infected eye with saline solution.
::::::**[[Gemifloxacin]] 320 mg PO in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose
:::::* 1.3.1 '''Management of sex partners'''
::::::**[[Gentamicin]] 240 mg IM in a single dose {{and}} [[Azithromycin]] 2 g PO in a single dose (alternative)
::::::* Patients should be instructed to refer their sex partners for evaluation and treatment.
::::::*Note: Use of [[Ceftriaxone]] or [[Cefixime]] is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
:::* 1.4 '''Disseminated gonococcal infection'''  
:::::*1.2.3 '''Pregnancy'''
:::::* 1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
:::::**Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
::::::* Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::**Chlamydia coinfection should be treated with azithromycin instead of doxycycline.  <br />
::::::* Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
:::::*1.2.4 '''Suspected cephalosporin treatment failure'''
::::::* Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h  for 7 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1 g PO in a single dose
:::::* 1.4.2 '''Gonococcal meningitis and endocarditis'''
::::::*Alternative regimen (1): [[Gemifloxacin]] 320 mg PO  single dose  {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::::::* Preferred regimen: [[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
::::::*Alternative regimen (2): [[Gentamicin]] 240 mg IM  single dose {{and}} [[Azithromycin]] 2 g PO single dose (when isolates have elevated cephalosporin MICs)
::* 2. '''Gonococcal infections among neonates'''
::::::*Alternative regimen (3): [[Ceftriaxone]] 250 mg IM as a single dose {{and}} [[Azithromycin]] 2 g PO as a single dose (failure after treatment with [[Cefixime]] and [[Azithromycin]])
:::* 2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
::::::*Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::*1.3 '''Gonococcal conjunctivitis'''
:::::* 2.1.1 '''Management of mothers and their sex partners'''
::::*Preferred regimen: a single 1 g IM dose of [[Ceftriaxone|ceftriaxone.]]
::::::* Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::::Note: A topical fluoroquinolone, saline irrigation are also recommended.
:::* 2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
:::::*1.3.1 '''Management of sex partners'''
::::* Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::::*Patients should be instructed to refer their sex partners for evaluation and treatment.
::::* Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV  q12h for 7 days.
:::*1.4 '''Disseminated gonococcal infection'''
::::* Note (1): The duration of treatment is 10-14 days if meningitis is documented.
:::::*1.4.1 '''Arthritis and arthritis-dermatitis syndrome '''
::::* Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
::::::*Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days.
:::::* 2.2.1 '''Management of mothers and their sex partners'''
::::::*Alternative regimen (1): [[Cefotaxime]] 1 g IV q8h for 7 days
::::::* Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::::::*Alternative regimen (2): [[Ceftizoxime]] 1 g IV q8h  for 7 days.
:::* 2.3 '''Neonates born to mothers who have gonococcal infection'''
::::::*Note: Once clinical improvement with [[ceftriaxone]] is noted for 24 to 48 hours, the regimen can be completed with intramuscular [[ceftriaxone]] (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
:::::*1.4.2 '''Gonococcal meningitis and endocarditis'''
:::::* 2.3.1 '''Management of mothers and their sex partners'''
::::::*Preferred regimen: [[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days
::::::* Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*2. '''Gonococcal infections among neonates'''<ref name="pmid333322962">{{cite journal| author=St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K | display-authors=etal| title=Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. | journal=MMWR Morb Mortal Wkly Rep | year= 2020 | volume= 69 | issue= 50 | pages= 1911-1916 | pmid=33332296 | doi=10.15585/mmwr.mm6950a6 | pmc=7745960 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332296  }}</ref><ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc=5885289 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815 }}</ref>
::* 3. '''Gonococcal infections among infants and children'''
:::*2.1 '''Ophthalmia neonatorum caused by N. gonorrhoeae'''
:::* 3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
::::* Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
::::*Recommended Regimen for prevention  '''Erythromycin''' '''0.5% ophthalmic ointment''' in each eye in a single application at birth
:::* 3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
:::::*2.1.1 '''Management of mothers and their sex partners'''
::::* Preferred regimen: [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Azithromycin]] 1g PO in a single dose
::::::*Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
::::* Alternative regimen: [[Cefixime]] 400 mg PO single dose {{and}} [[Azithromycin]] 1 g PO single dose.(If ceftriaxone is not available) 
:::*2.2 '''Disseminated gonococcal infection and gonococcal scalp abscesses in neonates'''
:::* 3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen (1): [[Ceftriaxone]] 25-50 mg/kg/day IM/IV q24h for 7 days
::::* Preferred regimen: [[Ceftriaxone]] 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
::::*Preferred regimen (2): [[Cefotaxime]] 25 mg/kg IM/IV  q12h for 7 days.
:::* 3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Note (1): The duration of treatment is 10-14 days if meningitis is documented.
::::* Preferred regimen: [[Ceftriaxone]] 1 g IM/IV q24h for 7 days
::::*Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
:::::*2.2.1 '''Management of mothers and their sex partners'''
::::::*Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
:::*2.3 '''Neonates born to mothers who have gonococcal infection'''
::::*Preferred regimen: [[Ceftriaxone]] 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)
:::::*2.3.1 '''Management of mothers and their sex partners'''
::::::*Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
::*3. '''Gonococcal infections among infants and children'''
:::*3.1 '''Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: '''[[Ceftriaxone]]''' 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)
:::*3.2 '''Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis'''
::::*Preferred regimen: [[Ceftriaxone]] 500 mg IM in a single dose.
::::*Alternative regimen:  '''[[Gentamicin]]''' 240 mg IM in a single dose  PLUS  '''[[Azithromycin]]''' 2 g PO in a single dose  OR  '''[[Cefixime]]''' 800 mg PO in a single dose
:::*3.3 '''Children who weigh ≤ 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)
:::*3.4 '''Children who weigh > 45 kg and who have bacteremia or arthritis'''
::::*Preferred regimen: [[Ceftriaxone]] 1 g IM or IV q24h for 7 days.
 
===Follow-Up===
A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated [[urogenital]] or [[rectal]] gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with [[pharyngeal]] gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or [[NAAT]]. If the [[NAAT]] is positive, effort should be made to perform a confirmatory culture before commencing retreatment.<ref name="CDC-Guidline"> Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016</ref>
 
*All positive cultures for test-of-cure should undergo [[antibiotic resistance|antimicrobial susceptibility]] testing
*Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
*If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment


==References==
==References==
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Latest revision as of 23:50, 2 September 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2] Nuha Al-Howthi, MD[3]

Overview

The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, Ceftriaxone is standard of care for treatment of gonorrhea. Routinely combining ceftriaxone with azithromycin for treatment of gonorrhea is no longer recommended.

Medical Therapy

Type of gonococcal infection Regimen
Uncomplicated Recommended regimen for urogenital, rectal, or pharyngeal gonorrhea
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
Uncomplicated Alternative regimen

(Add doxycycline 100 mg PO BID for 7 days if chlamydial infection has not been excluded)

(During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia).

Alternative regimens for severe Cephalosporin allergy or ceftriaxone not available
Arthritis and arthritis-dermatitis syndrome
Gonococcal meningitis and endocarditis

Antimicrobial Regimen

  • 1. Gonococcal infections in adolescents and adults
  • 1.1 Uncomplicated gonococcal infections of the urogenital, rectal, or pharyngeal gonorrhea.
  • 1.2 Uncomplicated gonococcal infections of the pharynx
  • pharyngeal infection is often asymptomatic and more difficult to eradicate than urogenital or anorectal gonococcal infections and may serve as a reservoir of infection.
  • Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb)
  • ceftriaxone 1 g IM, for persons weighing ≥150 kg (300 lb).
  • Chlamydial co-infection:
    • add doxycycline 100 mg PO BID 7 days. (In pregnancy azithromycin 1 g as a single dose)
    • No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended
  • 1.2.1 Management of sex partners
  • Expedited partner therapy: oral cefixime 800 mg orally once plus treatment for chlamydia is used for treatment of the partner.[5]
  • Note (1): expedited partner therapy is not routinely recommended for men who have sex with men.
  • Note (2): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
  • Note (3): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
  • Note (4): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
  • 1.2.2 Allergy, intolerance, and adverse reactions
  • 1.2.3 Pregnancy
    • Pregnant women with uncomplicated gonorrheal infection should be treated with the same preferred regimen as the general population.
    • Chlamydia coinfection should be treated with azithromycin instead of doxycycline.
  • 1.2.4 Suspected cephalosporin treatment failure
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with Cefixime and Azithromycin)
  • Note: Treatment failure should be considered in: (1) patients whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) patients with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
  • 1.3 Gonococcal conjunctivitis
Note: A topical fluoroquinolone, saline irrigation are also recommended.
  • 1.3.1 Management of sex partners
  • Patients should be instructed to refer their sex partners for evaluation and treatment.
  • 1.4 Disseminated gonococcal infection
  • 1.4.1 Arthritis and arthritis-dermatitis syndrome
  • Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days.
  • Alternative regimen (1): Cefotaxime 1 g IV q8h for 7 days
  • Alternative regimen (2): Ceftizoxime 1 g IV q8h for 7 days.
  • Note: Once clinical improvement with ceftriaxone is noted for 24 to 48 hours, the regimen can be completed with intramuscular ceftriaxone (500 mg for individuals <150 kg or 1 g for individuals ≥150 kg) every 24 hours.
  • 1.4.2 Gonococcal meningitis and endocarditis
  • Preferred regimen: Ceftriaxone 1-2 g IV q 12-24 h for 10-14 days
  • 2. Gonococcal infections among neonates[6][7]
  • 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose (not to exceed 250 mg)
  • Recommended Regimen for prevention Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth
  • 2.1.1 Management of mothers and their sex partners
  • Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates
  • Preferred regimen (1): Ceftriaxone 25-50 mg/kg/day IM/IV q24h for 7 days
  • Preferred regimen (2): Cefotaxime 25 mg/kg IM/IV q12h for 7 days.
  • Note (1): The duration of treatment is 10-14 days if meningitis is documented.
  • Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
  • 2.2.1 Management of mothers and their sex partners
  • Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.3 Neonates born to mothers who have gonococcal infection
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose. (not to exceed 250 mg)
  • 2.3.1 Management of mothers and their sex partners
  • Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
  • 3. Gonococcal infections among infants and children
  • 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 25–50 mg/kg IV or IM in a single dose. (not to exceed 250 mg)
  • 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 50 mg/kg IM or IV q24h for 7 days (maximum dose: 2 g)
  • 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 1 g IM or IV q24h for 7 days.

Follow-Up

A test-of-cure is not needed for patients who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, any person with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure using either culture or NAAT. If the NAAT is positive, effort should be made to perform a confirmatory culture before commencing retreatment.[8]

  • All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing
  • Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated
  • If retesting at 3 months is not possible, clinicians should retest whenever patients next present for medical care within 12 months following initial treatment

References

  1. ↑ "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR".
  2. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  3. ↑ "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR".
  4. ↑ "Gonococcal Infections Among Adolescents and Adults - STI Treatment Guidelines".
  5. ↑ St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K; et al. (2020). "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020". MMWR Morb Mortal Wkly Rep. 69 (50): 1911–1916. doi:10.15585/mmwr.mm6950a6. PMC 7745960 Check |pmc= value (help). PMID 33332296 Check |pmid= value (help).
  6. ↑ St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K; et al. (2020). "Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020". MMWR Morb Mortal Wkly Rep. 69 (50): 1911–1916. doi:10.15585/mmwr.mm6950a6. PMC 7745960 Check |pmc= value (help). PMID 33332296 Check |pmid= value (help).
  7. ↑ Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMC 5885289. PMID 26042815.
  8. ↑ Centers for disease control and prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm Accessed on September 14, 2016


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