Gonorrhea: Testing and Treatment of the gonococcal Urethritis
Review-Literature: (CDC Guidelines, 2012) (IUSTI Guidelines, 2012) (Moran, 2003) (Schneede et al, 2003).
Diagnosis of Gonorrhea
Indications for microbiological testing in men:
Urethral discharge, diagnosis of any other STI, sexual partners of patients with STI, acute epididymo-orchitis in a male aged
Indications for microbiological testing in women:
Vaginal discharge with risk factors for STI (history, age), diagnosis of any other STI, sexual partners of patients with STI, acute pelvic inflammatory disease.
should be done 4 h after voiding with inoculation of different culture media:
Two microscope slides:
for Gram stain (gonococcus) and Giemsa stain (Chlamydia), if a microscopic pathogen detection is sought. Over 4 leukocytes/field with intracellular gram-negative diplococci can be seen in gonorrhea with high power microscopy [fig. microscopy of gonorrhea].
Blood agar plates:
to detect Enterococcus, Streptococcus, Staphylococcus aureus ...
to detect Neisseria gonorrhoeae Martin-Lewis plates or Thayer-Martin agar should be used. Stuart medium to detect Mycoplasma and Ureaplasma. The detection of Chlamydia is done with PCR testing (see below) from the swab or seldom by growing in McCoy cell culture.
PCR testing (nucleic acid amplification tests):
PCR testing for gonorrhea or chlamydial infection has a high sensitivity and specifity, it is especially suitable to proove rectal or pharyngeal manifestation.
Further pathogen collection:
swab specimens collected from anus, pharynx, cervix, depending on history and symptoms.
study of the sexual partner:
to avoid a ping-pong-infection a detailed history and examination of any sexual partner is necessary.
after the urethral swab is collected, an urine culture from midstream should be started.
to exclude Syphilis, inappropriate for Chlamydia.
Treatment of Gonorrhea
Standard treatment (IUSTI, 2012):
Ceftriaxone 500 mg i.m. once. The IUSTI guideline recommends the subsequent treatment with azithromycin 2 g p.o. once. The combination with azithromycin is wise because of rising minimum inhibitory concentrations (MICs) in recent years. Azithromycin is also effective against Chlamydia or Ureaplasma. Diagnosis and co-treatment of the sexual partner(s) is very important.
The guideline of the CDC (2012) recommends lower doses of antibiotics: Ceftriaxon 250 mg i. m. once combined with azithromycin 1 g p.o. once.
Alternative treatments of second choice:
- Cefixim 400 mg 1-0-0 p.o. for 1(–3) days as an alternative to ceftriaxon in combination with Azithromycin. Resistance of Neisseria gonorrhoeae to cefixim is rising.
- If severe cephalosporine allergy is present: spectinomycin 2 g i.m. combined with azithromycin 2 g p.o. once.
- Doxycyclin 100 mg 1-0-1 for 7 days is an alternative to azithromycin.
- Both Ceftriaxon and azithromycin show sufficient efficacy against Neisseria gonorrhoeae. If one antibiotic is not available or allergies prohibit the use of the combination, the single use of ceftriaxon or azithromycin is sufficient.
- Due to rising resistance of Neisseria gonorrhoeae, fluoroquinolone antibiotics should only be used after proven sensitivity in cultural testing.
Follow up and test of cure:
Assessment is recommended two weeks after treatment with PCR testing. If testing confirms persisting gonococcal infection, antibiotic susceptibility testing should be done before further treatment. Patients with persisting symptoms after antibiotic treatment need also antibiotic susceptibility testing (one week after treatment) before further treatment.
Use of condoms, treatment with intravaginal nonoxynol-9 containing Spermacides, antibiotic prophylaxis after sexual intercourse, treatment of newborns eyes with antibiotic ointment.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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- Center for Disease Control & Prevention
- Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral
cephalosporins no longer a recommended treatment for gonococcal infections.
Morb Mortal Wkly Rep, 2012, 61, 590-594.
- Chris Bignell and Magnus Unemo
- European Guideline on the Diagnosis and Treatment of Gonorrhoea in Adults (2012). http://www.iusti.org/regions/Europe/euroguidelines.htm
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