Clinical Guide > Comorbidities and Complications > Gonorrhea

Gonorrhea and Chlamydia

January 2011

Chapter Contents

Background

Gonorrhea, caused by Neisseria gonorrhoeae (GC), and chlamydia, caused by Chlamydia trachomatis (CT), are sexually transmitted infections (STIs). These infections may be transmitted during oral, vaginal, or anal sex; they also can be transmitted from a mother to her baby during delivery and cause significant illness in the infant.

Both organisms can infect the urethra, oropharynx, and rectum in women and men; the epididymis in men; and the cervix, uterus, and fallopian tubes in women. Untreated GC or CT infection in women may lead to pelvic inflammatory disease (PID), which can cause scarring of the fallopian tubes and result in infertility or ectopic pregnancy (tubal pregnancy). The organisms also can affect other sites; N. gonorrhoeae can cause disseminated infection involving the skin, joints, and other systems. Infection with GC or CT may facilitate transmission of HIV to HIV-uninfected sex partners.

Certain strains of CT can cause lymphogranuloma venereum (LGV). This infection is common in parts of Africa, India, Southeast Asia, and the Caribbean. Outbreaks among men who have sex with men (MSM) have been reported in recent years in Europe and the United States. LGV may cause genital ulcers, followed by inguinal adenopathy; it also can (as seen in the recent cases among MSM) cause gastrointestinal symptoms, notably anorectal discharge and pain.

Patients with symptoms of gonorrhea or chlamydia should be evaluated and treated as indicated below. Although GC or CT urethritis in men typically causes symptoms, urethral infection in women and oral or rectal infections in both men and women often cause no symptoms. In fact, a substantial number of individuals with GC or CT infection have no symptoms. Thus, sexually active individuals at risk of GC and CT exposure should receive regular screening for these infections as well as for syphilis and other STIs. Patients frequently are infected with both GC and CT, so they should be tested and treated for both.

S: Subjective

Symptoms will depend on the site of infection (e.g., oropharynx, urethra, cervix, rectum). Symptoms are not present in all patients.

If symptoms are present, women may notice the following:

If symptoms are present, men may notice the following:

During the history, ask the patient about the following:

O: Objective

Physical Examination

During the physical examination, check for fever and document other vital signs.

For women, focus the physical examination on the mouth, abdomen, and pelvis. Inspect the oropharynx for discharge and lesions; check the abdomen for bowel sounds, distention, rebound, guarding, masses, and suprapubic or costovertebral angle tenderness; perform a complete pelvic examination for abnormal discharge or bleeding; check for uterine, adnexal, or cervical motion tenderness; and search for pelvic masses or adnexal enlargement. Check the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy.

For men, focus the physical examination on the mouth, genitals, and anus/rectum. Check the oropharynx for discharge and lesions, the urethra for discharge, the external genitalia for other lesions, and the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy.

A: Assessment

A partial differential diagnosis includes the following:

P: Plan

Diagnostic Evaluation

Test for oral, urethral, or anorectal infection, according to symptoms and possible exposures. Perform concurrent testing for both gonorrhea and chlamydia. The availability of the various testing methods varies according to the specific clinic site. Consider the following:

Treatment

Treatments for gonorrhea and chlamydia are indicated below. Fluoroquinolone-resistant GC is widespread in the United States, Pacific Islands, Asia, and Britain. Thus, the U.S. Centers for Disease Control and Prevention (CDC) recommends that fluoroquinolones not be used for treatment of GC in MSM or in any infected patient in the areas listed above, unless antimicrobial susceptibility test results are used to guide therapy. Similarly, resistance of GC to azithromycin is emerging, and azithromycin should be used to treat GC only in select patients in whom other treatments should be avoided.

Because dual infection is common, patients diagnosed with either GC or CT should receive empiric treatment for both infections, unless the other infection has been ruled out. Reinfection is likely if reexposure occurs. Any sex partners within the last 60 days, or the most recent sex partner from >60 days before diagnosis, also should receive treatment. Patients should abstain from sexual activity for 7 days after a single-dose treatment or until a 7-day treatment course is completed.

Adherence is essential for treatment success. Single-dose treatments maximize the likelihood of adherence and are preferred. Other considerations in choosing the treatment include antibiotic resistance, cost, allergies, and pregnancy. For further information, see the CDC STI treatment guidelines (see "References" below).

Treatment of Gonorrhea

Treatment options include the following (see the full CDC STI treatment guidelines, referenced below); the current guidelines emphasize that ceftriaxone should be used, if possible, for GC infection at any anatomic site and that azithromycin or doxycycline also should be given, to improve likelihood of cure and decrease risk of emergent cephalosporin resistance. Note that GC infection of the pharynx is more difficult to cure than GC infection at other sites. Patients who report possible oral sexual exposures should be treated with ceftriaxone 250 mg, if possible (see below).

Recommended regimens

Alternative regimens

(for GC infection of the urethra, cervix, and rectum ONLY; inadequate for pharyngeal GC)

If penicillin allergy:

Note: Fluoroquinolones are not recommended for treatment of gonococcal infection because of widespread resistance in the United States.

Please see full CDC STI treatment guidelines regarding treatment of PID, epididymitis, and disseminated gonococcal infection.

Treatment of Chlamydia

(See the full CDC STI treatment guidelines, referenced below.)

Recommended regimens

Alternative regimens

Treatment of LGV

Recommended regimens

Alternative regimens

For recent sex partners (within 6 days of the onset of patient's symptoms), test for urethral or cervical CT, treat with azithromycin 1 g PO in a single dose or doxycycline 100 mg PO BID for 7 days.

Treatment During Pregnancy

Use of fluoroquinolones and tetracyclines should be avoided during pregnancy.

Recommended GC regimens

Recommended CT regimens

Alternative CT regimens

Follow-Up

Patient Education

References

HRSA HAB Core Clinical Performance Measures