Gonorrhoea is a sexually transmitted disease caused by infection of mucosa with Neisseria gonorrhoeae (gonococcus), a Gram-negative bacterium. It occurs mainly as urethritis in men and cervicitis in women, but also as pharyngitis, proctitis, or conjunctivitis. Complications of gonococcal infections include pelvic inflammatory disease in women and epididymitis in men. Disseminated gonococcal infection results from gonococcal bacteraemia and may lead to septic arthritis, an arthritis-dermatitis syndrome (not to be confused with Reiter’s disease which has been associated with non-gonococcal or non-specific urethritis), and more rarely with conditions such as endocarditis or meningitis. Gonorrhoea in pregnant women may cause neonatal gonococcal conjunctivitis (ophthalmia neonatorum).
Infection with Chlamydia trachomatis often occurs along with gonorrhoea and should be tested for or treated presumptively.
N. gonorrhoeae used to be sensitive to penicillins and tetracyclines but in some areas, including Kenya, this is no longer the case. Gonococcal resistance includes plasmid-mediated penicillin resistance due to penicillinase-producing N. gonorrhoeae (PPNG), high-level plasmid-mediated tetracycline resistance (TRNG), and chromosomally mediated resistance (CMRNG) to penicillin, tetracycline, cefoxitin, or spectinomycin that is not due to beta-lactamase production.1
Although resistant strains of N. gonorrhoeae have generally been slower to emerge in Kenya than in some other parts of the world, increasing world travel and population mixing means that clinicians in the Kenya have to be aware of the possibility of antibacterial resistant infections. Increasing resistance of gonococci is now monitored in England and Wales via the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP).2 GRASP has reported increasing resistance to fluoroquinolones and current UK guidelines3 recommend single doses of spectinomycin or ceftriaxone intramuscularly, or cefixime orally for the treatment of uncomplicated anogenital gonorrhoea. Single doses of ciprofloxacin or ofloxacin are alternatives unless the organism can be demonstrated to be fully sensitive to penicillins, in which case ampicillin plus probenecid may be used.3
In the USA, the wide distribution of antimicrobial-resistant N. gonorrhoeae, as documented by the Gonococcal Isolate Surveillance Project,1 has necessitated revised treatment guidelines. The Centers for Disease Control (CDC)4 recommends single-dose cephalosporins or fluoroquinolones as the treatment of choice for uncomplicated gonorrhoea, rather than penicillin or tetracycline, plus treatment for chlamydial infection (see below for details).
Of concern are the increasing number of reports worldwide of resistance to newer antigonococcal drugs such as the fluoroquinolones.
uncomplicated gonococcal infections in adults.
WHO (for anogenital infections): a single oral dose of ciprofloxacin 500¬†mg or cefixime 400¬†mg, or a single intramuscular dose of ceftriaxone 125¬†mg or spectinomycin 2¬†g.
CDC (for uncomplicated infections in general): a single oral dose of cefixime 400¬†mg, or ciprofloxacin 500¬†mg, or ofloxacin 400¬†mg, or levofloxacin 250¬†mg, or a single intramuscular dose of ceftriaxone 125¬†mg. Other cephalosporins or fluoroquinolones may be substituted. Spectinomycin 2¬†g as a single intramuscular dose is an alternative in patients who cannot tolerate cephalosporins or fluoroquinolones. For pharyngeal infections a single oral dose of ciprofloxacin 500¬†mg, or a single intramuscular dose of ceftriaxone 125¬†mg is recommended. (In the UK,3 these drugs are also recommended for pharyngeal infections, although the recommended dose for ceftriaxone is 250¬†mg; a further recommended alternative is ofloxacin 400¬†mg orally as a single dose.) In each case CDC also advocates treatment for presumptive chlamydial infections with either azithromycin 1¬†g orally as a single dose or doxycycline 100¬†mg twice daily for 7 days.4
CDC recommends a cephalosporin or spectinomycin for pregnant women with gonorrhoea, and erythromycin or amoxicillin for chlamydial infection.4
gonococcal eye infections in adults.
WHO5 recommends a single dose of ceftriaxone 125¬†mg intramuscularly, or spectinomycin 2¬†g intramuscularly, or ciprofloxacin 500¬†mg by mouth, together with frequent irrigation of the infected eye with saline. Kanamycin 2¬†g intramuscularly is another alternative.
CDC4 recommends a single dose of ceftriaxone 1¬†g intramuscularly together with irrigation of the infected eye with saline.
disseminated gonococcal infections in adults.
WHO5 recommends ceftriaxone 1¬†g intramuscularly or intravenously once daily for 7 days or spectinomycin 2¬†g intramuscularly twice daily for 7 days. Another third-generation cephalosporin may be substituted if neither of these drugs is available.
CDC4 recommends the following regimens: initially ceftriaxone 1¬†g intramuscularly or intravenously every 24 hours; alternatives are ceftizoxime 1¬†g intravenously every 8 hours or cefotaxime 1¬†g intravenously every 8 hours. Ciprofloxacin 400¬†mg intravenously every 12 hours, or ofloxacin 400¬†mg intravenously every 12 hours, or levofloxacin 250¬†mg intravenously once daily, or spectinomycin 2¬†g intramuscularly every 12 hours may be substituted in patients allergic to beta lactams. Once improvement has been established for 24 to 48 hours, oral therapy with cefixime 400¬†mg twice daily, or ciprofloxacin 500¬†mg twice daily, or ofloxacin 400¬†mg twice daily, or levofloxacin 500¬†mg once daily may be substituted until at least a 1-week treatment period is complete. For gonococcal meningitis and endocarditis, CDC advises ceftriaxone 1 to 2¬†g intravenously every 12 hours; treatment for meningitis should continue for 10 to 14 days and for endocarditis for at least 4 weeks.
gonococcal infections in neonates and children.
Neonates born to mothers with gonorrhoea are at high risk of infection and require prophylaxis.
WHO5 recommends a single intramuscular injection of ceftriaxone 50¬†mg/kg (maximum 125¬†mg) or, if ceftriaxone is not available, spectinomycin 25¬†mg/kg (maximum 75¬†mg) or kanamycin 25¬†mg/kg (maximum 75¬†mg).
CDC4 recommends a single intramuscular or intravenous injection of ceftriaxone 25 to 50¬†mg/kg (maximum 125¬†mg). For those neonates with disseminated gonococcal infection (sepsis, arthritis, meningitis), ceftriaxone 25 to 50¬†mg/kg intramuscularly or intravenously once daily for 7 days or cefotaxime 25¬†mg/kg intramuscularly or intravenously every 12 hours for 7 days is recommended, in each case extended to 10 to 14 days if meningitis is present. The prevention and treatment of neonatal gonococcal conjunctivitis is discussed under Neonatal Conjunctivitis, .
The treatment recommended by CDC4 for children with gonococcal infections, most commonly due to sexual abuse in pre-adolescents, is as for adults in those weighing 45¬†kg or more. For those weighing less than 45¬†kg, CDC recommends a single intramuscular dose of ceftriaxone 125¬†mg or spectinomycin 40¬†mg/kg (maximum 2¬†g) for those with uncomplicated infections. For disseminated infection in all children they recommend an intramuscular or intravenous dose of ceftriaxone 50¬†mg/kg once daily for 7 days, up to a maximum dose of 1¬†g in those weighing less than 45¬†kg.