Gonorrhoea diagnosis and management

Last updated: December 2019

Diagnosis

Note: NAAT refers to Nucleic Acid Amplification Test, such as PCR

Presumptive

Gram stain smear – presence of typical intracellular Gram negative diplococci (GNID)

Confirmed

Culture of urethral, rectal or pharyngeal swab

  • typical colonial morphology on selective culture medium, typical Gram stain morphology, positive oxidase reaction confirmed with sugar utilisation, coagglutination or antigonococcal fluorescent antibody testing

Positive NAAT on first catch urine sample or other specimen

Where a gonococcal NAAT test is positive, gonococcal culture should always be taken from the same site prior to treatment, for antimicrobial sensitivity testing.

Gonococci have developed resistance to multiple classes of antibiotics, including penicillins, and quinolones over the past decades. Azithromycin resistant strains have recently been detected in South Australia. Decreased susceptibility to oral cephalosporins has been reported, mostly in Asian countries, and a few cases of resistance to ceftriaxone, or treatment failure from ceftriaxone, have been reported, in Asia, Europe and Australia. Recent history of travel should be elicited in patients with gonorrhoea.

NB: To identify antibiotic sensitivities, culture must be taken from all NAAT positive anatomical sites prior to treatment, and as a test of cure one week after treatment.

Treatment

Doses given here are adult doses.

Children weighing more than 45 kilograms should receive adult regimens. If less than 45 kilograms check paediatric guidelines for dosing.

Gonoccocal uncomplicated ano-genital

Standard therapy

Ceftriaxone 500 mg IMI as a single dose (B1) with Azithromycin 1gm orally (B1).

Observe patient in clinic for 15 minutes after administration.

There is no readily available oral therapy recommended for routine treatment of gonorrhoea in South Australia.

Alternate therapeutic regimens carry a risk of treatment failure. The patient must be informed of this and that attendance for test of cure one week post-treatment is mandatory.

Gonococcal uncomplicated pharyngeal infection

Ceftriaxone 500mg IMI as a single dose (B1) with Azithromycin 2gm orally (B1) PLUS metoclopramide 10mg as a single dose

Alternate therapy

Gentamicin 240mg IMI (D) as a single dose into a large muscle, ideally gluteal. (Due to large volume, give as two injections at separate sites) WITH Azithromycin 2 gm orally (B1) PLUS metoclopramide 10mg as a single dose.

Gentamicin is contraindicated in pregnancy.

Ceftriaxone is not contraindicated for use in pregnancy (Category B1). Where ceftriaxone is contraindicated in a pregnant woman due to allergy, contact Adelaide Sexual Health Centre for advice

Azithromycin 2g orally as a single dose PLUS Metoclopramide 10mg as a single dose.

Gonococcal conjunctivitis in adults

Ceftriaxone 1gm IMI in a single dose (B1) with Azithromycin 1gm orally (B1).

Gonococcal opthalmia

Can rapidly progress to rupture of the ocular globe and blindness and should be considered an ophthalmic emergency. Early referral to an ophthalmologist is essential.

Gonococcal opthalmia neonatorum

Early treatment and urgent referral to a specialist centre are essential. Ensure mother is tested, treated and contact traced.

Disseminated gonococcal infection

Ceftriaxone 1gm IMI or IV daily for 7 days (B1)

Disseminated gonococcal infection can cause septic emboli, septic arthritis, endocarditis, or meningitis – ensure urgent specialist review.

Epidemiologic treatment

Epidemiologic treatment refers to treatment with standard regimens, after laboratory tests have been taken, but before confirmatory results are available, on the basis that the benefits of treating outweigh the benefits of not treating.

The following patients should receive epidemiologic treatment:

  • those who are contacts of a person with proven gonorrhoea
  • those from whom an endocervical, urethral, rectal or conjunctival smear shows intracellular Gram negative diplococcic

Current gonococcal treatment regimens include azithromycin 1gm orally which provides epidemiological treatment for uncomplicated chlamydial infections.

Patient education

The following points should be discussed

  • the importance of immediate testing and treating of all sex partners
  • abstinence from sex until a test of cure is performed
  • patient education/provision of literature on gonorrhoea
  • that gonorrhoea is a notifiable disease.

Partner notification (contact tracing)

Stress the importance of partner notification and treating sexual partners.

Inform patients about asymptomatic infections, potential complications of untreated infection and the possibility of re-infection if a partner is not treated.

Advise patients to have no sexual contact for 7 days after treatment.

Advise no sex with sexual partners from the last 2 months until the partners have been tested and treated.

Test and treat contacts of a person with gonorrhoea on the same day (do not wait for confirmatory results).

Web resources are available for patients to inform partners anonymously:

The Australasian Contact Tracing Guidelines are a resource for medical professionals.

Follow up

Test of cure should be done at one week after treatment with a culture test in all cases where culture has been positive. Test of cure is crucial for monitoring for treatment failure, and is critical where a first line regimen cannot be used.

NAAT tests are not suitable for tests of cure as they can remain positive for several weeks after treatment due to the detection of non-viable pathogen DNA.

All patients should return 7 to 10 days after completion of treatment for

  • evaluation of symptoms and signs
  • check reaction to medication
  • enquiry about sexual activity since treatment
  • culture from infected sites (test of cure) to include rectal culture from all women with endocervical gonorrhoea
  • ensure contact tracing has occurred
  • screen for other STIs (if not done already) and arrange follow up at three months for blood borne virus serology and syphilis testing.

Advise condom use until serology at three months in case of concomitant undiagnosed HIV, syphilis or hepatitis.

Further information

For further information on the diagnosis and management of gonorrhoea contact Adelaide Sexual Health Centre.

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Adelaide Sexual Health Centre staff and some flexibility is required in applying them to certain private practice situations.