New Guidelines for Gonorrhea Treatment

Lindee Abe, APRN

Gonorrhea is typically an easy to treat diagnosis in medicine. The Centers for Disease Control and Prevention have issues new guidelines for gonorrhea treatment. It requires a single dose of ceftriaxone in clinic (unless there is an allergy to cephalosporins). We should treat Gonorrhea if there is a known or suspected exposure or while pending testing results. But what if we reach a time when we can no longer reliably treat gonorrhea with the antibiotics available? This is concerning due to the potential complications of untreated gonorrhea. Complications are not the only reason it should be concerning. This is a giant warning flag that we are reaching a time when we may no longer have the tools necessary to treat bacterial diseases.

The CDC has been closely monitoring antibiotic resistance trends and the findings are concerning. The United Kingdom warned of a “super gonorrhea” strain in the United Kingdom several years ago. This strain was closely monitored internationally. The UK strain was resistant to the recommended ceftriaxone and azithromycin protocol recommended at that time.

Antibiotic Stewardship

Antibiotic resistance is a growing concern amongst the medical community. The CDC is now stressing the importance of antibiotic stewardship and only prescribing antibiotics when clinically indicated. The CDC even provides handouts to give to patients on their website regarding antibiotic resistance. So why is it so hard? For anyone that has worked in a clinic, urgent care, or emergency room during the winter months the answer is multifactorial. It takes far less time to prescribe an antibiotic then to educate the patient on why they don’t need an antibiotic and also discuss other treatments that may be more beneficial for them. At first this sounds lazy, but many urgent cares will have the provider seeing more than one patient every 15 minutes during peak seasons.

Some patients simply “need” antibiotics despite our reassurance. If a patient leaves the clinic thinking that they should have been given an antibiotic – and weren’t – their encounter can score poorly in satisfaction surveys. Antibiotic stewardship is the responsibility of all providers. The mentality of “this one prescription won’t matter” leads to antibiotic resistance and to changes to treatment protocols for common infections like gonorrhea.

Gonorrhea Treatment Recommendations

Let’s start by discussing gonorrhea treatment recommendations. Previously, Gonorrhea was treated with a single injection of Ceftriaxone (250 mg). Oral treatment with azithromycin (1 gram) or doxycycline (100mg twice daily for 2 weeks) were also given. The ceftriaxone was the treatment for gonorrhea and the azithromycin was treatment for chlamydia. This provided more coverage than ceftriaxone alone and slow the emergence of a gonorrhea resistant to ceftriaxone. If a patient was exposed to gonorrhea, they have also likely been exposed to chlamydia. Chlamydia can be asymptomatic and left untreated can cause permanent complications, such as infertility and scarring of the fallopian tubes.

There is also the concern for compliance and getting the patient to return to the clinic for additional treatment. Some states even recommend “observed therapy” or having the patient take the azithromycin in front of staff. This requires having access to azithromycin or a pharmacy in the clinic in order to do the observed therapy, which is often a limiting factor for most clinics.

Empiric Treatment

In 2020, the CDC updated the guidelines for gonorrhea treatment due to increased drug resistance. The treatment recommendations changed from 250mg of ceftriaxone to 500mg of ceftriaxone IM injection once. Any patient over 300 lbs should receive ceftriaxone 1 gram IM. In the case of cephalosporin allergy, the recommended alternate treatment regimen is 240 mg IM gentamicin with 2 gram azithromycin dose orally. The new guidelines also removed the recommendation of treatment with azithromycin to cover potential chlamydia infection. This change is due to the increasing resistance of bacteria to azithromycin. There is also the added stress of antibiotic stewardship. You should also treat Chlamydia unless you can exclude it with a negative test. The following patients should receive empiric treatment:

• Do not want testing
• Cannot afford prescriptions
• Are not likely to be compliant with treatment as an outpatient

The recommended treatment regimen for chlamydia has changed from azithromycin 1 gram to doxycycline 100mg BID for 7 days.

Exceptions to treatment

There are some noted exceptions to the recommended treatment. For example, if the potential site of gonorrhea is other than the genitourinary tract. The pharynx is another less common site that needs treatment. Studies have shown that it is likely that gonorrhea in the pharynx requires a longer duration of therapy in order to completely treat and reduce the incidence of recurrence. This does not change the dosing recommendation for initial treatment, but does include the recommendation for test of cure 7-14 days after initial treatment. There are also no recommendations for alternate treatment regimen for pharyngeal gonococcal infection. The anus and rectum are other alternate sites of infection. The treatment for this infection the same regimen used for genitourinary gonorrhea. Locations outside of the genitals should be tested with nucleic acid amplification testing (NAAT). Send cultures if you suspect treatment failure. These will allow for susceptibility testing.

Disseminated Gonorrhea

Disseminated gonorrheal infection typically results in a widespread joint pain for the patient. If a sexually active patient comes in with wide spread joint pain and was previously heathy, then the provider should at least consider this as a possibly and rule it out through aspiration of joint fluid and testing. While wide spread joint pain is typically the presenting symptom, disseminated gonorrhea is often accompanied by a diffuse rash.

Test of Cure

Another common question comes to test of cure and when is it appropriate. As noted above, Test of cure is recommended after treatment for pharyngeal gonococcal infection. The CDC states that routine test of cure is not necessary for uncomplicated cases of gonorrhea treated with the appropriate regimen. However, they also noted a 7-12% recurrence rate for patients who test positive for gonorrhea at 12 months after initial diagnosis. For this reason, they recommend repeat testing at 3 months whenever possible. It is unlikely for a patient to have a false positive if retested by NAAT more than 7 days after treatment for gonorrhea.

It is essential for providers to stress the importance of abstaining from sexual intercourse for 7 days following treatment. We also recommend testing and treating all recent sexual partners in the past 60 days. With a one time injection of ceftriaxone, some patients may assume that they are fine to return to normal sexual activity immediately following the injection. The patients should know that this can result in infecting their partner, if not already infected, and can result in multiple courses of therapy if reinfection occurs.

Resources:

Barbee, L. & Golden, M. (2016). When to Perform a Test of Cure for Gonorrhea: Controversies
and Evolving Data. Clinical Infectious Diseases, 62, 1356-1359.

St. Cyr S, Barbee L, Workowski, KA, et al. Update to CDC’s Treatment Guidelines for
Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020; 69; 1911-1916. DOI:
https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm#suggestedcitation.