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Gonorrhea: Testing and Treatment of the gonococcal Urethritis

• Gonorrhea: Etiology, Signs and Symptoms
• Gonorrhea: Diagnosis and Treatment

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 <40 years.

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.

Urethral swab:

should be done 4 h after voiding, the microbiological diagnosis is possible with different techniques::

PCR testing:

PCR testing for gonorrhea or chlamydial infection has a high sensitivity and specificity.

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].

Special media:

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.

Further pathogen collection:

swab specimens collected from anus, pharynx, cervix, depending on history and symptoms.

Test of the sexual partner:

to avoid a ping-pong-infection a detailed history and examination of any sexual partner is necessary.

Urin analysis:

after the urethral swab is collected, an urine culture from midstream should be started.

Serological tests:

of other STD like Syphilis, Hepatitis and HIV.

Notifiable disease:

Notifiable disease in some countries e.g., USA or Canada, but not in e.g., UK, France or Germany.

Treatment of Gonorrhea

Standard treatment (IUSTI, 2020):

Ceftriaxone 1 g i.m. once. The IUSTI guideline (2020) 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 (2020) recommends lower doses of antibiotics: Ceftriaxon 500 mg i. m. once, a combination with azithromycin or docycycline in uncomplicated cases is only necessary when chlamydial infection has not been excluded.

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.
• 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.

Prevention:

Use of condoms, treatment with intravaginal nonoxynol-9 containing Spermacides, antibiotic prophylaxis after sexual intercourse, treatment of newborns eyes with antibiotic ointment.

References

Schneede u.a. 2003 SCHNEEDE, P. ; TENKE, P. ; HOFSTETTER, A. G.: Sexually transmitted diseases (STDs)-a synoptic overview for urologists.
In: Eur Urol
44 (2003), Nr. 1, S. 1–7

  Deutsche Version: Gonorrhoe: Diagnose und Therapie der gonorrhoischen Urethritis.