Gonorrhoea treatment guidelines

Gonorrhoea is caused by Neisseria gonorrhoeae.

There is higher prevalence of gonorrhoea among:

• MSM, especially if they take PrEP
• remote Aboriginal and Torres Strait Islander communities
• street-based sex workers
• sexual contacts of people with gonorrhoea

In recent years, there has been a rising notification rate among heterosexual male and females.

Women

Men

Testing notes

NAAT tests such as transcription mediated amplification (TMA), polymerase chain reaction (PCR) and strand displacement amplification (SDA) are more sensitive than culture in detecting gonococci.

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. gonorrhoeae genome can improve the specificity of NAATs for gonorrhoea and help to exclude false positive results.

Patients who have been screened positive for gonorrhoea using AC-2 testing and who are recalled for treatment should have culture taken from the NAAT-positive site prior to treatment: urethral, pharyngeal, rectal, or cervical. This includes asymptomatic MSM for urethral swab as culture can be positive even where discharge is absent.

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

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 obtained from a urethral swab, endocervical swab or anal swab:

• GNDC are virtually always seen in the discharge from men with urethral gonorrhoea, but less frequently in cases of gonococcal cervicitis or proctitis
• Neisseria 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

Testing methods

Testing methods depend on the risk group of the individual.

Women

• Screening of women for gonorrhoea is recommended
• 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).
  • Refer to Vaginal discharge treatment guidelines for information about vaginal discharge and other relevant tests in women with discharge
• Women should be tested for gonorrhoea by NAAT testing from a vaginal or cervical swab:
  • Urine can be used but may be less sensitive
  • If gonorrhoea NAAT is positive, then a cervical swab for gonorrhoea culture should be obtained prior to treatment for antimicrobial susceptibility testing

Heterosexual men

• Screening of heterosexual men for urethral gonorrhoea is recommended because of the increasing prevalence of this infection among heterosexuals
• Men who present with urethral discharge, particularly purulent discharge and/or where there is risk for gonorrhoea (such as MSM, overseas contact, contact with gonorrhoea) should be tested for gonorrhoea using two methods:
  • urine for NAAT testing
  • swab of the urethral discharge for culture
• Culture should be obtained at presentation prior to treatment for antimicrobial susceptibility testing

MSM

• Asymptomatic MSM should be screened for pharyngeal and rectal gonococcal at least once a year, with more frequent screening of higher risk men as part of comprehensive testing for other STI and HIV
• MSM taking PrEP should be screened for gonorrhoea at their 3 monthly PrEP visits
• Screening of MSM should include urine (gonorrhoea and chlamydia) and pharyngeal (gonorrhoea and chlamydia) and anal (gonorrhoea and chlamydia) swabs
  • Refer to Chlamydia treatment guidelines

Contacts of gonorrhoea

• Individuals who report sexual contact with gonorrhoea should be screened for gonorrhoea by NAAT:
  • Women: pharyngeal swab and cervical swab
  • Heterosexual men: pharyngeal swab and urine
  • MSM: pharyngeal and anal swabs and urine

Index patient

Gonorrhoea is notifiable to the Victorian Department of Health.

Patients with medication allergies

A history of rash or urticaria following penicillin is not necessarily a contraindication to treatment with ceftriaxone. However, if there is a history of anaphylaxis following penicillin, or those with documented allergy to cephalosporins, an alternative to ceftriaxone should be used.

Treatment choice will depend on prevailing patterns of antimicrobial resistance. Options to be considered for initial treatment include Azithromycin 2 g together with doxycycline 100 mg twice daily for 7 days.

Combination therapy is preferred to monotherapy because of concerns about inducing resistance if single-drug therapy is used. There is no evidence for this combination.

A single 2 g dose of azithromycin has been shown to be effective in >95% of uncomplicated susceptible genital, pharyngeal and rectal infections. However, this dose commonly causes significant gastrointestinal upset and should be taken with food (1 g stat followed by 1 g, 6-12 hours later)

In patients unable to tolerate this combination, consider:

• Azithromycin 2 g alone, as divided dose (1 g stat followed by 1 g, 6-12 hours later)

or

• Doxycycline 100 mg twice daily for 7 days

​or

• Ciprofloxacin 500 mg single dose

High level resistance

Gonococcal isolates with high level resistance to ceftriaxone (MIC ≥0.125) and/or azithromycin (MIC ≥256) should be discussed with a senior MSHC sexual health physician and be reported to the Victorian Department of Health and Human Services and Partner Notification Officers, so that close follow up of the index case with test of cure and outbreak investigation are conducted to limit the further transmission of highly resistant gonorrhoea.

There is a formal procedure that has been adopted by the Victorian Department of Health and Human Services for managing such cases which is initiated when the Partner Notification Officers are contacted. The sexual partners of individuals with highly resistant gonorrhoea should attend MSHC and be tested and if found to have gonorrhoea have test of cure performed after treatment. These partners will be referred to MSHC for testing and treatment by the Partner Notification Officers.

Recall patients for a test of cure if: non-standard gonorrhoea treatment is given (e.g. ceftriaxone was not given because of concerns about allergy) or ceftriaxone MIC is ≥0.06 (less susceptible)

• Tests of cure for gonorrhoea are only required if a non-standard treatment regimen has been used to treat gonorrhoea or if the results of antibiotic susceptibility testing indicate resistance to ceftriaxone/and or azithromycin. Clinicians should ask patients to attend for a test of cure if ceftriaxone is not used.
• Tests of cure should be with culture one week after treatment from the site(s) of infection and not NAAT as the former will be positive only if gonococci are viable whereas the latter may be positive from non-viable material.

Partners should be contacted and tested; sex with untreated gonorrhoea infected partners can result in repeat infection.

Consider referring patients to Let Them Know. This site supports patients to notify partners and facilitates SMS and email messages to partners.

Treatment for gonorrhoea is not routinely offered to asymptomatic individuals reporting contact with gonorrhoea because a proportion will be negative for gonorrhoea, therefore avoiding administration of ceftriaxone. However, treatment can be offered if the patient prefers, has symptoms, or is unlikely to return for the test result or treatment.

If the contact is being treated for gonorrhoea at the initial visit, gonorrhoea culture of these sites should also be performed

Individuals should abstain from sex with their partners until 7 days after both have received treatment.