2009 European (IUSTI/WHO) Guideline on the Diagnosis and Treatment of Gonorrhoea in Adults

Gonorrhoea (meaning ‘flow of seed’) and its related clinical manifestations are caused by infection with the bacterium Neisseria gonorrhoeae;

Infection predominantly involves the columnar epithelium of the urethra, endocervix, rectum, pharynx and conjunctivae. Although it usually remains localized to the initial sites of infection, it can ascend the genital tract to cause pelvic inflammatory disease (PID) and epididymo-orchitis or disseminate as bacteraemia;

Transmission is by genital–genital, genital–anorectal, orogenital or oro–anal contact or by mother-to-child transmission at birth;

The highest incidence of gonorrhoea is in young adults (15–29 years) and there is a disproportionate burden of disease in ethnic minority groups and men who have sex with men (MSM).^1,2

In men, the predominant presentation is of acute urethritis with symptoms of urethral discharge and dysuria;

In women, symptoms relate to endocervical and urethral infection and include increased or altered vaginal discharge, intermenstrual bleeding, dysuria and menorrhagia;

Asymptomatic genital tract infection occurs in women (up to 50%) and men (up to 10%). Rectal and pharyngeal infections are usually asymptomatic. ⁷

In men, the most common finding on examination is a mucopurulent urethral discharge, which may be accompanied by erythema of the urethral meatus;

In women examination may be normal or a mucopurulent discharge may be evident from the cervix, sometimes accompanied with hyperaemia and contact bleeding of the endocervix.

The diagnosis of gonorrhoea is established by identification of N. gonorrhoeae in genital, rectal, pharyngeal or ocular secretions;

Microscopy using Gram or methylene blue staining offers good sensitivity (≥95%) and specificity as a rapid diagnostic test in symptomatic men with urethral discharge. ⁴ Microscopy has poor sensitivity (≤55%) in asymptomatic men and in identifying endocervical (≤55%) or rectal infection (≤40%) and cannot be recommended as a test of exclusion in these situations;^4,6

Culture offers a specific and cheap diagnostic test that readily allows confirmatory identification and antimicrobial susceptibility testing. Selective culture media containing antimicrobials are recommended ⁸ (level of evidence III; grade B recommendation). Culture is appropriate for endocervical, urethral, rectal and pharyngeal specimens. The sensitivity of culture is high for genital samples providing that specimen collection, transport and isolation procedures are good. An appropriate quality control is needed for the gonorrhoea culture system since commercial media vary in their selectivity and sensitivity. Culture should be performed if symptoms persist following treatment;

Nucleic acid amplification tests (NAATs) are generally more sensitive (≥90%) than culture. ^9,10 They can be used on urine samples, self-taken vaginal swabs and swabs from the endocervix and urethra. Female urine samples offer a lower sensitivity than swabs from the genital tract and are not recommended. Samples giving a positive NAAT result should be subjected to confirmatory testing,^11–13 i.e. repeated with a NAAT targeting another sequence (level of evidence III; recommendation level B). The positive predictive value of unconfirmed positive NAAT results in low prevalence populations is suboptimal;

NAATs are significantly more sensitive than culture from pharyngeal and rectal swabs. ¹⁴ Commercially available NAATs are not licensed for use on specimens from these sites. If they are used after laboratory evaluation, confirmatory testing is mandatory^14b (level of evidence IIb; grade B recommendation);

Women may have genital tract infection localized to the endocervix or urethra. A single endocervical or vaginal sample tested by a NAAT offers sufficient sensitivity (90%) for screening purposes;^15,16

A minority of MSM with gonorrhoea (20–30%) have infection at multiple sites. Tests should be taken from the urethra/urine, rectum and pharynx as directed by sexual practices.

Symptoms or signs of urethral discharge in men;

Vaginal discharge with risk factor for STI (age <30 years, new sexual partner);

Mucopurulent cervicitis;

Sexually partner of a person with sexually transmitted infection (STI) or PID;

Acute epididymo-orchitis in male aged <40 years;

Acute PID;

Screening of young adults for STI;

Screening individuals with new or multiple recent sexual partners;

Purulent conjunctivitis in a neonate.

Patients should be advised to avoid sexual intercourse until they and their partners have completed treatment and they are asymptomatic (level of evidence IV; grade C recommendation);

Patients should be given a detailed explanation of their infection together with clear written information (level of evidence IV; grade C recommendation).

Antimicrobial resistance is a major determinant of treatment efficacy and has severely limited treatment options.^17–20 Therapy recommended in this guideline adheres to the standard of ≥95% microbiological cure rate at genital sites in summed clinical trials;^20,21

Resistance of N. gonorrhoeae to antimicrobials continues to evolve across Europe and in vitro resistance to penicillin, tetracyclines and quinolones exceeds 10% of isolates tested in many countries.^1,17 Resistance to azithromycin is increasing with high-level resistance recently reported in the UK.^22–24 There remains significant geographical variation in resistance and local alternative treatments based on local surveillance data of resistance may be reasonable.

Identification of intracellular Gram-negative diplococci at a genital site by microscopy;

Positive culture or confirmed NAAT from any site for N. gonorrhoeae (unconfirmed NAAT from urogenital specimens from high-risk patients);

On epidemiological grounds, if a recent partner has confirmed gonococcal infection;

On demonstration of a purulent urethral discharge in men or mucopurulent cervicitis in women when rapid diagnostic tests are not available and after specimen collection for laboratory testing. In this circumstance, combined treatment for gonococcal and chlamydial infection should be given.

Ceftriaxone 250 mg intramuscular (IM) as a single dose (level of evidence Ib; grade A recommendation). If ceftriaxone 250 mg for IM injection is not available, the IM suspension can be mixed as follows: 3.5 mL of 10 mg/mL lidocaine without adrenalin is suspended into a 1 g vial of ceftriaxone and mixed. One millilitre of the mixture is drawn and injected IM;

Cefixime 400 mg oral as a single dose (level of evidence Ib; grade A recommendation);

Spectinomycin 2 g IM as a single dose (level of evidence Ib; grade A recommendation).

Other single-dose cephalosporin regimens.

Single-dose quinolone regimens.

Azithromycin.

Recommended treatments for pharyngeal infection:

Ceftriaxone 250 mg IM as a single dose (level of evidence Ib; grade A recommendation);

Alternative treatments for pharyngeal infection when quinolone or azithromycin resistance excluded or highly unlikely: ciprofloxacin 500 mg as a single oral dose or azithromycin 2 g as a single oral dose.

Recommended treatments (level of evidence Ib; grade A recommendation): ³³

Ceftriaxone 250 mg IM as a single dose;

Or

Cefixime 400 mg as a single oral dose;

Or

Spectinomycin 2 g IM as a single dose;

Pregnant and breast-feeding women should not be treated with quinolone or tetracycline antimicrobials.

Recommended treatment:

Spectinomycin 2 g IM as a single dose;

Alternative treatments in patients with known β-lactam allergy when quinolone or azithromycin resistance excluded or highly unlikely: ciprofloxacin 500 mg as a single oral dose or azithromycin 2 g as a single oral dose.

According to the European Guideline on epididymo-orchitis recommended treatment:

Doxycycline 100 mg twice daily for 14 days;

+;

Either ceftriaxone 250 mg IM or ciprofloxacin 500 mg stat according to local knowledge of antibiotic sensitivities.

Recommended treatment (level of evidence IV; grade C recommendation): ³⁴

Initial therapy:

Ceftriaxone 1 g IM or IV every 24 hours; or

Cefotaxime 1 g IV every 8 hours; or

Spectinomycin 2 g IM every 12 hours.

Recommended treatments: ²⁷

Ceftriaxone 25–50 mg/kg IV or IM as a single dose not to exceed 125 mg; or

Cefotaxime 100 mg/kg IM as a single dose;

Frequent conjunctival irrigation with saline.

Sex partners should be contacted and offered testing and treatment for gonorrhoea and chlamydial infection (level of evidence IV; grade C recommendation);

For cases of gonorrhoea, all sex partners within the preceding 60 days of diagnosis should be evaluated and treated ²⁰ (level of evidence IV; grade C recommendation). If a patient's last intercourse was more than 60 days prior to their diagnosis, their last sexual partner should be evaluated.

Assessment after treatment is recommended to confirm compliance with therapy, resolution of symptoms and signs, and partner notification (level of evidence IV; grade C recommendation);

A test of cure is not routinely necessary for anogenital infection if a recommended treatment has been given. Indications for test of cure include (level of evidence IV; grade C recommendation): ○

Persistence of symptoms;

Re-exposure to infection;

When there is possible antimicrobial resistance to the therapy given;

When stipulated by national or local practice;

Pharyngeal infection.