Clinical Guide > Comorbidities and Complications > Gonorrhea

Gonorrhea and Chlamydia

January 2011

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:

• Vaginal discharge
• Urinary hesitancy
• Pain with sexual intercourse
• Pain or burning on urination
• Abdominal or pelvic pain
• Sore throat
• Mouth sores
• Rectal discharge
• Anal discomfort

If symptoms are present, men may notice the following:

• Increased urinary frequency or urgency
• Urethral discharge
• Red or swollen urethra
• Incontinence
• Pain on urination
• Testicular tenderness or pain
• Rectal discharge
• Anal discomfort

During the history, ask the patient about the following:

• Any of the symptoms listed above, and their duration
• Previous diagnosis of gonorrhea or chlamydia
• New sex partner(s)
• Unprotected sex (oral, vaginal, anal)
• For women: last menstrual period, and whether the patient could be pregnant; use of an intrauterine device

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:

• Urinary tract infection
• Dysmenorrhea
• Apendicitis
• Cystitis
• Procytis
• PID
• Irritable bowel syndrome
• Pyelonephritis

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:

• Culture (oropharynx, endocervix, urethra, rectum)
• Nucleic acid amplification test (NAAT): urine specimens (first stream) and urethral (men), vaginal, and endocervical swab specimens; also used with pharyngeal and rectal swab specimens (although not yet FDA approved for this use)
• Nucleic acid hybridization assay (DNA probe): endocervical and male urethral swab specimens; not approved for rectal or pharyngeal swabs
• Gram stain (pharyngeal, cervical, or urethral discharge), for evidence of GC
• Serologic tests (microimmunofluorescence test or complement fixation test) for suspected LGV

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

• Ceftriaxone 250 mg IM injection in a single dose, plus azithromycin 1 g PO in a single dose or doxycycline 100 mg PO BID for 7 days (for pharyngeal GC, this is the only recommended regimen)
  
  If ceftriaxone is not an option; for GC of the urethra, cervix, and rectum ONLY:
  • Cefixime 400 mg PO in a single dose (tablet or oral suspension), plus azithromycin or doxycycline as above; cefixime is NOT sufficiently effective to treat pharyngeal GC
  • Single-dose injectable cephalosporin plus azithromycin or doxycycline as above; efficacy for pharyngeal GC is uncertain

Alternative regimens

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

• Cefpodoxime 400 mg PO in a single dose
• Cefuroxime axetil 1 g PO
• Spectinomycin 2 g IM injection in a single dose (currently not available in the United States)
• Azithromycin 2 g PO in a single dose (concern for possible emergence of resistance; use other agents if possible)

If penicillin allergy:

• Cephalosporins are contraindicated only in patients with a history of severe reaction to penicillin.
• Consultation with an infectious disease specialist is recommended.
• Spectinomycin can be used for urogenital or rectal infection (inadequate for pharyngeal GC).
• Azithromycin 2 g PO; use caution owing to concerns over emerging resistance to macrolides.
• Consider cephalosporin treatment following desensitization.

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

• Azithromycin 1 g PO in a single dose
• Doxycycline 100 mg PO BID for 7 days

Alternative regimens

• Erythromycin base 500 mg PO QID for 7 days
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days
• Ofloxacin 300 mg PO BID for 7 days (see Note above)
• Levofloxacin 500 mg PO once daily for 7 days (see Note above)

Treatment of LGV

Recommended regimens

• Doxycycline 100 mg PO BID for 21 days

Alternative regimens

• Erythromycin base 500 mg PO QID for 21 days
• Azithromycin 1 g PO once weekly for 3 weeks (limited data)

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

• A recommended cephalosporin or azithromycin 2 g PO (see above)

Recommended CT regimens

• Azithromycin 1 g PO in a single dose
• Amoxicillin 500 mg PO TID for 7 days

Alternative CT regimens

• Erythromycin base 500 mg PO QID for 7 days
• Erythromycin base 250 mg PO QID for 14 days
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days
• Erythromycin ethylsuccinate 400 mg PO QID for 14 days

Follow-Up

• Evaluate the patient's sex partners; treat them empirically if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms. (Some clinics provide empiric treatment for partners via "partner packs," or a treatment regimen that the patient takes to the partner(s); this approach does not require the partner to present for evaluation and may be effective if the partner(s) is/are unlikely to come to the clinic.)
• Most recurrent infections come from sex partners who were not treated.
• If symptoms persist, evaluate for the possibility of reinfection, treatment failure, or a different cause of symptoms. If treatment failure is suspected, perform culture and antimicrobial sensitivity testing.
• The CDC recommends rescreening male patients 3 months after treatment.
• For pregnant women with chlamydia, retest (by culture) 3 weeks after completion of treatment.
• Screen for gonorrhea, chlamydia, syphilis, and other STIs at regular intervals according to the patient's risk factors. The sites of sampling (e.g., pharynx, urethra, endocervix, anus/rectum) will be determined according to the patient's sexual exposures.
• Evaluate each patient's sexual practices with regard to the risk of acquiring STIs and of transmitting HIV; work with the patient to reduce sexual risks.

Patient Education

• Instruct patients to take all of their medications. Advise patients to take medications with food if they are nauseated and to call or return to clinic right away if they experience vomiting or are unable to take their medications.
• Sex partners from the previous 60 days need to be tested for sexually transmitted pathogens, and treated as soon as possible with a regimen effective against GC and CT, even if they have no symptoms. Advise patients to inform their partner(s) that they need to be tested and treated. Otherwise, patients may be reinfected.
• Advise patients to avoid sexual contact until the infection has been cured (at least 7 days).
• Provide education about sexual risk reduction. Instruct patients to use condoms with every sexual contact to prevent reinfection with GC or CT, to prevent other STIs, and to prevent transmission of HIV to sex partners.

References

• Abularach S, Anderson J. Gynecologic Problems. In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005.
• Centers for Disease Control and Prevention. Gonorrhea--CDC Fact Sheet.
• Centers for Disease Control and Prevention. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men--United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR. 2004 Apr 30;53(16):335-8.
• Centers for Disease Control and Prevention. Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR. 2004 Oct 29;53(42):985-8.
• Centers for Disease Control and Prevention. Male Chlamydia Screening Consultation--Review and Guidance. May 25, 2007.
• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010 Dec 17; 59 (No. RR-12):1-110.
• Centers for Disease Control and Prevention. Update of sexually transmitted diseases treatment, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR. 2007 Apr; 56(14):332-336.