Gonorrhoea

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Gonococcal infection can lead to genital as well as extragenital (pharyngeal and rectal) infection. In women infection can cause cervicitis which may be asymptomatic or result in vaginal discharge. Upper genital infection can lead to pelvic inflammatory disease.

In men gonorrhoea can cause urethritis which is characterised by a purulent urethral discharge. In men who have sex with men infection of the pharynx and rectum are common and may be present alongside urethral infection. Infections of the pharynx are asymptomatic. Rectal infections are usually asymptomatic but in a proportion cause symptoms of proctitis with anal pain and discharge.

Conjunctival infection can occur in neonates born to infected mothers and in adults via exposure to infected genital secretions. Disseminated gonococcal infection, characterised by arthritis and skin lesions is rare.

Gonorrhoea is less common among heterosexual men and women in Australian cities. Prevalence is higher among men who have sex with men (MSM), travellers from countries where gonorrhoea is more common, among some remote Aboriginal and Torres Strait Islander communities and among street based sex workers. Individuals reporting sex with a partner with gonorrhoea are more likely to be infected.

DIAGNOSIS

Nucleic acid amplification tests (NAAT) such as transcription mediated amplification (TMA), polymerase chain reaction (PCR) and strand displacement amplification (SDA) are more sensitive than culture in detecting gonococci. However, false positive gonococcal NAAT results do occur especially in low prevalence populations. Interpret unexpected positive results with caution in low-risk patients. Confirmatory testing by the laboratory using a NAAT test that targets a different part of the N. gonorrhoea genome can improve the specificity of NAATs for gonorrhoea and help to exclude false positive results.

Culture provides an isolate for antimicrobial susceptibility testing which is important for surveillance of antimicrobial resistance which is growing.

Testing methods depend on the risk group of the individual.

Men who have sex with men

Asymptomatic MSM should be screened for pharyngeal and anorectal gonococcal infection at least once a year, with up to 3 monthly screening of higher risk men as part of comprehensive testing for other STI and HIV. This should include pharyngeal and anal swabs for gonorrhoea. .Urethral gonorrhoea usually presents with discharge but can be asymptomatic in some men.

Heterosexual men

Screening of low risk heterosexual men in Australian cities for gonorrhoea is not recommended because of the low prevalence and risk of false positive results.

Men who present with urethral discharge, particularly purulent discharge and/or where there is risk for gonorrhoea (e.g. MSM, overseas contact, contact with gonorrhoea) should be tested for gonorrhoea using urine NAAT. If NAAT is used a swab of the discharge for culture should also be obtained at presentation prior to treatment for antimicrobial susceptibility testing.

Heterosexual women
As with men, screening of low risk heterosexual women in Australian cities for gonorrhoea is not recommended because of the low prevalence and risk for false positive result.

Women who present with vaginal discharge should be examined for signs of cervical inflammation and tested for gonorrhoea, especially where there is increased risk for gonorrhoea (overseas contact, contact with gonorrhoea). Please refer to MSHC treatment guideline on vaginal discharge for other relevant tests in women with discharge.

Women can be tested by NAAT using a vaginal or endocervical swab Or First pass urine . If gonorrhoea NAAT is positive then a swab for gonorrhoea culture should be obtained for antimicrobial susceptibility testing prior to treatment

Where microscopy is available, microscopy can help confirm a diagnosis of gonorrhoea, and therefore guide treatment at the initial visit, by identifying gram negative (intracellular) diplococci (GNDC) in a gram stain of the discharge. GNDC are virtually always seen in discharges from men with urethral gonorrhoea, but less frequently in cases of gonococcal cervicitis or proctitis.

Note that N meningitidis, though an uncommon cause of urethritis and cervicitis can cause a purulent discharge clinically indistinguishable from gonorrhoea. GNDC seen in meningococcal discharges are morphologically identical to gonococci.

TREATMENT

Recommendations on the treatment of gonorrhoea are changing because of the development of antimicrobial resistance by N. gonorrhoeae. Resistance to ciprofloxacin and penicillin is now common in Victoria. Authorities now recommend combination treatment using ceftriaxone and azithromycin. If an individual reports anaphylaxis or severe allergy to cephalosporins or penicillin, advice on alternative treatment should be obtained from a sexual health specialist.

Uncomplicated infections

For uncomplicated urethral, cervical, pharyngeal and rectal gonorrhoea use:

  • Ceftriaxone 500 mg in 2 ml of 1% lignocaine as a single intramuscular injection plus
  • Azithromycin 1 gram as a single dose

Note:If a result on a gonorrhoea culture test is received prior to treatment being administered and this result shows sensitivity to ciprofloxacin, ciprofloxacin 500mg orally ( stat) can then be used instead of ceftriaxone and azithromycin. However it is not recommended that treatment is delayed waiting for sensitivities.

Gonococcal epididymo-orchitis

Severe cases of gonococcal epididymo-orchitis should be admitted to hospital for intravenous therapy. For mild to moderate cases:

  • Azithromycin 1 gram as a single dose plus
  • Ceftriaxone 500mg in 2ml of 1% lignocaine by intramuscular injection* plus either
  • Doxycycline 100mg twice daily for 14 days

*Men with gonococcal epididymo-orchitis should be reviewed closely: further doses of ceftriaxone may be warranted. 

Gonococcal PID

Severe cases of gonococcal PID should be admitted to hospital for intravenous therapy. For mild to moderate cases:

  • Azithromycin 1 gram as a single dose plus
  • Ceftriaxone 500mg in 2ml of 1% lignocaine by intramuscular injection** plus
  • Metronidazole 400mg twice daily for 14 days plus either
  • Doxycycline 100mg twice daily for 14 days

**Women with gonococcal PID should be reviewed closely: further doses of ceftriaxone may be warranted.

FOLLOW UP

MSHC does not recommend performing a test of cure following treatment for gonorrhoea routinely. However, a repeat test should be performed if treatment failure is suspected or if a treatment other than those recommended are used. A test of cure that is positive in the absence of sexual re-exposure suggests potential treatment failure. If NAAT is used it should not be performed within 7 days of treatment as a positive result may represent DNA detection from non-viable organisms. Suspected treatment failures involving gonorrhoea isolates resistant to ceftriaxone and/or azithromycin should be discussed with a sexual health specialist. Individuals who are sexually active following treatment for gonorrhoea may be at risk of re-infection by untreated partners or new partners and should be encouraged to have repeated screening.

CONTACTS

Partner notification should be discussed with patients diagnosed with gonorrhoea as sex with untreated gonorrhoea infected partners can result in repeat infection. Consider referring patients to the Let Them Know website (www.letthemknow.org.au)   which is designed to support patients to undertake partner notification and which facilitates sending of SMS and email messages to partners. Partners should be contacted, tested and treated for gonorrhoea without waiting for their test results. Individuals should abstain from sex with their partners until 7 days after both have received treatment.

NOTIFICATION

Gonorrhoea is notifiable to the Victorian Health Department and a notification form should be completed.

 

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated January 2017