Gonorrhoea management

Cases of gonorrhoea and contacts of gonorrhoea should ideally be managed at Borders Sexual Health where culture plates and microscopy facilities are available.

Diagnosis

Testing should be done routinely with NAAT samples. Cultures are required for anyone who is known or suspected to have gonorrhoea and is to be treated with antibiotics: i.e. those presenting with suggestive symptoms, who are presumptively diagnosed by microscopy or are contacts of infection.

So – if treatment is given, cultures should be taken.

In contacts of gonorrhoea, or those with a confirmed (NAAT) or presumptive (microscopy) diagnosis of gonorrhoea at a single site, samples for NAAT and culture testing should be taken from all susceptible sites. These may include:

• Pharyngeal NAAT testing.
• Vulvovaginal swab for NAAT. This can be a self-taken swab.
• Endocervical culture N. gonorrhoeae - unlike NAAT testing, this specimen must be taken from the endocrevix and not vulvo-vagina.
• First voided urine (FVU) specimen for NAAT.
• Urethral culture in men.
• Rectal NAAT and culture testing.

Treatment of Uncomplicated gonorrhoea

• Ceftriaxone 1g IM

Partner notification

Look back period:

• 2 weeks in male patients with symptomatic urethral infection
• 3 months in all other of cases

Management of Contacts

Epidemiological treatment is only recommended for those presenting within 14 days of exposure. After this time, test NAATS unless regular partner and likely to have sex ie index patient before 14 days is over.

Follow up and Test of Cure (TOC)

• NAAT tests done 3 weeks after treatment.
• Only required from initially positive sites.
• Confirm no problems with treatment and no risk of re-infection.
• If a positive TOC, cultures should be repeated prior to any retreatment PN arrangements and actions.

Men

• Urethral gonorrhoea is usually symptomatic (>80%), commonly presenting with a purulent discharge and dysuria.
  
  • More rarely, if the infection spreads to the posterior urethra, there may be symptoms of urinary frequency, urgency and painful erections.
• A small proportion of men may present only with dysuria or no symptoms.
• Rectal infection is usually asymptomatic but may cause discharge (12%) or give non specific symptoms of itch and discomfort.
• Pharyngeal infection is usually asymptomatic.

Women

• Vaginal discharge is the most common symptom in endocervical infections, although 50% of cases are asymptomatic.
• Rarely, infection causes menstrual irregularities (intermenstrual and/ or heavy bleeding) and low abdominal pain.
• Rectal and pharyngeal infections are usually asymptomatic.

Complications:

• Local complications:
  
  • Men:
    
    • Epididymitis (or epididymo-orchitis) and prostatitis.
    • Inflammation of surrounding urethral structures (parafrenular and para-urethral glands) with cellulitis and abscess formation.
  • Women:
    
    • Pelvic inflammatory disease.
    • Rarely perihepatitis.
    • Inflammation of paraurethral structures (Skene glands) and vestibular glands (Bartholin’s abscess).
• Disseminated infection (uncommon): arthritis, tenosynovitis, skin lesions, meningitis, pericarditis and endocarditis.

Testing should be done routinely with NAAT samples.

• Cultures are required for anyone who is known or suspected to have
  gonorrhoea and is to be treated with antibiotics: i.e. those presenting with suggestive symptoms, who are presumptively diagnosed by microscopy or are contacts of infection.

Sampling in contacts of gonorrhoea, or those diagnosed with gonorrhoea at a single site:

Men who are contacts of a female partner with gonorrhoea, or are known to have urethral gonorrhoea:

• NAATs: First void urine and pharyngeal sample
• Cultures: Urethral and pharyngeal for N.gonorrhoeae

Men who are contacts of a male partner with gonorrhoea, or are known to have urethral gonorrhoea:

• NAATs: FVU, rectal and pharyngeal sample
• Cultures: urethral, rectal and pharyngeal culture for N.gonorrhoeae

Women who are who are contacts of a male partner with gonorrhoea or who are to be treated for a presumptive diagnosis of gonorrhoea:

• NAATs: vulvovaginal, rectal and pharyngeal.
• Cultures: cervical, rectal and pharyngeal.

Nucleic acid amplification techniques (NAAT)

• Preferred method and performed in dual testing with Chlamydia trachomatis.
  
  • The local test performed at the SSTBRL is the Abbott M2000.
• Positive tests are confirmed by an in house PCR test platform increasing the positive predictive value to more than 99%.

Microscopy

Available at Galashiels Health Centre Dr Clinic

• Detects more than 95% of cases of symptomatic urethral gonorrhoea in men.
• In women, microscopy of urethral or cervical samples is much less sensitive (<40%) as there are many other bacteria morphologically identical to NG (N meningitides, Moraxella catarrhalis, etc). Microscopy is reserved for those in whom there is a high index of clinical suspicion (possible contacts, purulent cervical or urethral discharge).
• Sensitivity of microscopy for rectal samples is lower still (28%) and should be reserved for those in whom there is a high index of clinical suspicion.
• Microscopy should not be performed on pharyngeal samples (high rates of asymptomatic carriage of Neisseria meningitides).

Cultures

• Culture is the only way of detecting AMR strains.
  
  • To be done in cases presenting with symptoms suggestive of gonorrhoea, positive NAAT tests and on contacts of the infection, prior to prescription of any treatment.
• We use a MNYC (modified New York City) medium plate that contains a base of rich nutrients with added LACT (Lincomycin, Amphotericin, Colistin and Trimethoprim) for the inhibition of other organisms.
  
  • It requires a warm and humid environment (36° C and the presence of CO2).
  • Cultures are also confirmed at the lab with additional tests: microscopy, morphology of colonies, oxidase test and sugars.
• Cultures should sample urethra/pharynx in heterosexual men; urethra/pharynx/rectum in MSM and endocervix/pharynx/rectum in
  women.

Correct plating techniques, including for urethral samples in men, as follows:

1. Uncomplicated gonorrhoea

• Ceftriaxone 1g IM
  Prepare with 1 g vials diluted with Lidocaine 1% 3.5 ml.

See BASHH Guidance 2018 for discussion around rational for this treatment option.

Contraindications to the administration of ceftriaxone include hypersensitivity to any cephalosporin or to any of the excipients listed in the product packaging or history of severe hypersensitivity (e.g. anaphylactic reaction) to any other type of beta-lactam antibacterial agent (penicillins, monobactams and carbapenems).

• Ciprofloxacin 500mg orally ONLY if result of resistance testing is available.
  Ciprofloxacin resistance in the UK is high (33.7% in 2016).

Alternatives:

• Azithromycin 2g orally.
  Taken with food may ameliorate potential gastrointestinal side effects.
  High level resistance in UK.

Treatment failure has been documented to the following options particularly when used to treat pharyngeal infection. Therefore it is recommended that dual therapy with Azithromycin 2G is used.

• Cefixime 400 mg orally with Azithromycin 2G orally stat dose.
  Low level resistance in UK currently.
  Only use if IM injection contraindicated or refused.
• Spectinomycin 2 g IM with Azithromycin 2G orally stat dose.
  Not licensed in UK.
  Difficult to obtain (see suppliers*).
• Gentamicin 240mg intramuscularly as a single dose plus
  Azithromycin 2g orally.
• Quinolones (ciprofloxacin 500 mg or ofloxacin 400 mg orally).
  Not generally recommended as high level of resistance reported.
  Only use if strain known to be sensitive.

In the event of resistance or allergy, discuss with GUM senior.

Penicillin allergy

There is negligible cross reactivity with cephalosporins. In
severe or immediate reactions:

• Azithromycin 2 g oral single dose (with food).
• Spectinomycin 2 g + azithromycin 2g oral single dose.
• Ciprofloxacin 500 mg oral OR Ofloxacin 400 mg oral single dose (Only when known sensitivities).

2. Complicated infections:

Pregnancy and Breast feeding

• Ceftriaxone 1G IM
• Spectinomycin 2G IM
• Azithromycin 2G orally

PID

• Ceftriaxone 1g IM followed by doxycycline 100 mg bd and metronidazole 400 g bd orally 14 days.

Epididymo-orchitis

• Ceftriaxone 1g IM follow by doxycycline 100 mg bd 14 days orally.

Conjunctivitis

• Ceftriaxone 1g IM single dose

Disseminated gonococcal infection (DGI)

• Ceftriaxone 1g IV/IM 24 hourly 7 days (this can be switched after
  24-48hours to oral treatment depending on progress) to
  
  • Cefixime 400mg bd
  • Ciprofloxacin 500mg bd
  • Ofloxacin 400mg bd

Partner notification

• Look back period:
  
  • 2 weeks in male patients with symptomatic urethral infection.
  • 3 months in all the rest of cases.
• All partners should be tested (at all susceptible sites).

Treatment of contacts

Epidemiological treatment is not needed for all sexual contacts, and ideally
treatment should only be given to those partners who test positive for
gonorrhoea.

However, an infection may be missed if a test is performed too soon after a potential exposure. The time between exposure and a positive test result may vary depending on a number of host, pathogen and diagnostic factors.

Therefore, in order to reduce the unnecessary use of antibiotics, we
recommend the following:

• For those presenting after 14 days of exposure we recommend
  definitive NAAT testing and treatment only following a positive test for gonorrhoea.
• For those presenting within 14 days of exposure we recommend considering epidemiological treatment based on a clinical risk assessment and following a discussion with the patient.
• Those accepting epidemiological treatment should be told NOT to
  have sex until they have had a negative test of cure at 3 weeks
  OR
• The patient may wish to be tested and if this test is negative be
  retested at 14 days post exposure and treat only a positive result. They should not have sex until they have a negative definitive NAAT test.

• 3 weeks after treatment - NAATs
• Confirm no problems with treatment and no risk of re-infection
• Review PN arrangements and actions

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