Gonorrhoea

Clinicians in metropolitan Perth need to be aware that gonorrhoea cases have more than doubled since 2010 and the rate of increase has jumped steeply since the beginning of 2016.

The Clap poster (PDF 734KB) has been developed for display in patient areas to help raise awareness of this public health issue amongst consumers.

Organism

Gonorrhoea is caused by Neisseria gonorrhoeae (N. gonorrhoeae), a Gram-negative intracellular diplococcus (GNID).

Clinical presentation

Gonorrhoea is asymptomatic in 80% of women and 10% to 15% of men.

Gonorrhoea is an STI characterised by one or more of the following:

  • a urethral discharge (urethritis) and/or burning sensation (dysuria)
  • cervical discharge (cervicitis) and/or intermenstrual or post-coital bleeding
  • anorectal infection (proctitis) with discharge, painful defecation, disturbed bowel function or irritation 
  • pharyngeal infection
  • pelvic inflammatory disease (PID) and associated dyspareunia (pain during vaginal intercourse)
  • prostatitis (very rarely)
  • epididymitis
  • conjunctivitis
  • skin lesions

Rarely

  • disseminated disease is uncommon but serious; it can present as septic arthritis, meningitis, endocarditis, sepsis, and macular rash that may include necrotic pustules. 

STI Atlas (external site)

Investigations

A definitive diagnosis of gonorrhoea is established by detecting N. gonorrhoeae in a clinical specimen by culture or by NAAT. Culture swabs are recommended whenever possible so that antimicrobial susceptibilities can be obtained. Serious resistance to gonorrhoea is emerging with few treatment options in the future being available, and antimicrobial surveillance is a vital public health measure.

A presumptive diagnosis of gonorrhoea is achieved by:

  • demonstrating at least two GNID in a smear made from a male urethral swab. Absence of neutrophils or gonococci on Gram stain does not exclude gonorrhoea.
  • demonstrating GNID in a smear from a patient with clinical features compatible with gonococcal infection.

Men

If there is a discharge, take a urethral swab of the discharge for smear and transport charcoal (black) or non-charcoal (clear) agar gel transport medium for culture and sensitivity. Collect first void urine (FVU) for NAAT. If the patient is unable to pass urine, collect a dry urethral swab of the discharge for NAAT (no transport medium).
  • Detecting GNID in a urethral smear is a reliable indicator of gonorrhoea, but the absence of diplococci does not exclude the diagnosis. For these reasons, always collect samples for culture and NAAT.
  • If there is no discharge (a rare situation in male urethral gonorrhoea), collect FVU for NAAT.
  • If the patient has had receptive anal sex, oro-anal sex, rimming or fingering, and no anal symptoms: Patients can be instructed how to take two blind anal swabs himself or herself. Refer to the STI self-testing card (PDF 346KB) for instructions. However, if the patient presents with anal symptoms, collect a dry swab of the discharge for NAAT (no transport medium) and a second swab under direct vision of the rectal mucosa via a proctoscope and transport in charcoal (black) or non-charcoal (clear) agar gel transport medium for culture and sensitivity.
  • If the patient has had receptive anal sex, and no oral symptoms, take a throat swab for NAAT (no transport medium). 

Women

  • If cervical pus is present or the cervix is inflamed, collect a dry swab of the discharge for NAAT (no transport medium) and a second swab under direct vision of the cervix via a vaginal speculum and transport in charcoal (black) or non-charcoal (clear) agar gel transport medium for culture and sensitivity.. Endocervical swabs are essential for culture and high vaginal swabs are not adequate for culture. If the patient has had a hysterectomy, urine for NAAT must be collected.
  • If there is no discharge, self-obtained vaginal swabs are the preferred specimen. Add a first void urine (FVU) specimen where possible. If the patient is examined take an endocervical swab for NAAT (no transport medium) in addition to FVU testing. A urine specimen only, is acceptable if a woman declines to give either a vaginal or endocervical swab but will miss some cervical infections
  • Diagnosis and treatment of infected patients prevents ongoing/further transmission to sex partners and, for infected pregnant women, may prevent transmission of gonorrhoea to infants during birth.
  • If the patient has had receptive anal sex, oro-anal sex, rimming or fingering, and no anal symptoms: Patients can be instructed how to take two blind anal swabs himself or herself. Refer to the STI self-testing card (PDF 346KB) for instructions.
  • If the patient has had receptive oral sex, and no oral symptoms, take a throat swab for NAAT (no transport medium). 

Specimen collection and handling

  • It is important to collect suitable specimens before treatment because the diagnosis of gonorrhoea relies heavily on detecting the organism by culture or NAAT. Serology is not useful for gonorrhoea testing.
  • When delays of greater than 24 hours occur in getting the specimen to a laboratory (e.g. in rural and remote areas) NAAT is the preferred test. However, where there is pus, a culture should still be sent.

Special considerations

  • Allow slides to air-dry before sealing and labelling.
  • Clearly label all specimens with the patient's name, date of birth or medical record number, and the site, date and time of collection.
  • Specimens for culture should reach the laboratory as quickly as possible and preferably within 24 hours of collection.
  • If swabs for culture are unlikely to be processed in the laboratory within 24 hours of collection, they should still be sent, although the yield will be diminished.

See further information on methods of testing, including use of GeneXpert point-of-care test in health services where this is available. 

Treatment

The treatment of gonorrhoea in WA must be guided by the current antimicrobial susceptibility profile.

Treating uncomplicated gonorrhoea

Adults

Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to this treatment. 

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly

        and

  • azithromycin 1 g (orally), given together as a single treatment

Pregnancy

Treatment in pregnancy is the same as non-pregnant individuals 

Children

  • ceftriaxone 50 mg/kg (maximum 500 mg) intramuscularly (using the adult dilution)

        and

  • azithromycin 20 mg/kg (to a maximum of 1 g) (oral tablet or syrup), given together as a single treatment

Uncomplicated gonorrhoea excludes:

  • PID
  • epididymitis
  • ophthalmic lesions
  • prostatitis
  • arthritis
  • disseminated infections.

Chlamydia co-infection

The chlamydia co-infection rate among patients with heterosexually acquired gonorrhoea is about 40%

Because of the high risk of co-infection, treat all symptomatic patients who are suspected to have gonorrhoea, for chlamydia as well.

For suspected urethral and cervical infections, azithromycin 1mg stat (with ceftriaxone 500mg IMI as for gonorrhoea infection) will be adequate. 

For rectal co-infection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:

  • ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
plus
  • azithromycin 1g PO, stat
and

  • doxycyline 100mg PO, BD 7 days if asymptomatic, but 21 days if symptomatic (internationally recognised treatment)
or
  • azithromycin 1g PO, stat, followed by azithromycin 500mg PO daily for 2 days (alternative treatment)

Treating gonorrhoea in other clinical situations

Allergy to penicillin

Delayed type hypersensitivity (rash)

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly, (Note: should not be used when the allergy to penicillin is recorded as severe and/or hypersensitivity is immediate)
  • azithromycin 1 g (orally), given together as a single treatment

Severe or immediate type hypersensitivity (anaphylaxis, Stevens Johnson syndrome, toxic epidermal necrolysis)

  • azithromycin 2 g (orally) - may cause gastro-intestinal intolerance
  • seek advice from a sexual health specialist

Regarding ciprofloxacin

  • ciprofloxacin should no longer be used for empirical treatment due to increasing resistance profiles. It should only be used when culture has demonstrated ciprofloxacin susceptibility.
  • ciprofloxacin should not be used in children under 12 years or pregnant women.

Pharyngeal gonorrhoea

Adults

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly
  • azithromycin 1 g (orally), given together as a single treatment

Children

  • ceftriaxone 50 mg/kg (maximum 500 mg) intramuscularly (using the adult dilution)
  • azithromycin 20 mg/kg to a maximum of 1g (oral tablet or syrup) given together as a single treatment

Special considerations

  • amoxycillin monotherapy should not be used in either adults or children for gonococcal pharyngeal infections because of the difficulty in achieving an adequate concentration of antibiotic in tissues and cells.

Anorectal gonorrhoea 

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly
plus
  • azithromycin 1 g (orally), given together as a single treatment

Prophylactic treatment of neonates

  • ceftriaxone 50 mg/kg (maximum 250 mg) intramuscularly, as a single dose.

Gonococcal conjunctivitis

This disease is most often sporadic due to either auto-inoculation in a person with genital gonorrhoea or from contaminated fingers or fomites (clothes, towels) from another person with genital gonorrhoea. Rarely epidemics may occur in remote communities due to non-sexual transmission from direct contact, fomites or vectors such as flies.

Gonococcal conjunctivitis should be treated as follows:

Adults

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly,

        and

  • azithromycin 1 g (orally), given together as a single treatment

        plus

  • frequent irrigation of the eyes with saline to remove purulent discharge.

Children

  • ceftriaxone 50 mg/kg (maximum 500 mg) intramuscularly (using the adult dilution)

        and

  • azithromycin 20 mg/kg to a maximum of 1g (oral tablet or syrup) given together as a single treatment

        plus

  • frequent irrigation of the eyes with saline to remove purulent discharge.

Management of sporadic disease

A case of gonococcal conjunctivitis in a remote Aboriginal community may herald an outbreak. Gonococcal conjunctivitis in a child may indicate sexual abuse. Therefore all suspected and confirmed cases of gonococcal conjunctivitis should be notified as soon as possible to the local PHU for further investigation.

For a sporadic case of gonococcal conjunctivitis anywhere in WA all contacts should be reviewed and any suspect cases sampled and treated empirically as for the index case. In certain situations such as in remote Aboriginal communities empiric treatment of asymptomatic contacts may be undertaken immediately under the guidance of the PHU to help prevent further dissemination.

Management of an epidemic situation

Epidemics of gonococcal conjunctivitis are a public health emergency and the local PHU should be immediately notified. All confirmed and suspected cases and their asymptomatic household and family contacts should be treated immediately. In remote Aboriginal communities in the Goldfields, Kimberley and Pilbara regions of WA, procaine penicillin (single dose) or amoxycillin (child: 75 mg/kg up to 3 g) orally PLUS probenecid (child >2 years: 25 mg/kg up to 1 g) orally (single dose) may be used. It is important that the index case and all contacts are treated within the same 24-hour period to prevent reinfection.

Neonatal

  • ceftriaxone 50 mg/kg (maximum 125 mg) intravenously or intramuscularly, daily for seven days

        plus

  • frequent irrigation of the eyes with saline to remove purulent discharge.

Special considerations

  • Mothers of neonates with gonococcal eye disease should be tested for other STIs and treated for genital gonococcal infection.
  • Also test the neonate for chlamydia.
  • Specialist advice should be obtained when treating people with serious penicillin allergy. These patients are at risk of anaphylaxis, collapse, breathing difficulties or urticaria if exposed to penicillin or cephalosporin.
  • Contact the local PHU as soon as possible.

Treating gonorrhoea complicated by associated infections

  • PID
  • epididymitis
  • ophthalmic lesions
  • prostatitis
  • septic arthritis
  • disseminated infections.

These conditions require multiple dose therapy and individualised care. Specialist advice should be sought.

PID presents with a range of mild to severe infection. The condition may closely mimic such abdominal emergencies as acute appendicitis or ectopic pregnancy. Such circumstances warrant hospitalisation, as do PID in pregnancy, inability to tolerate oral therapy, or suspected pelvic abscess.

Related links

Education, counselling and prevention

Counselling is important in managing STIs/HIV and should be considered at every contact with the patient.

As a minimum, consider counselling at the first presentation and subsequently during treatment and follow-up.

  • Counselling is an opportunity to educate and support the patient in prevention strategies. This should be done in a confidential setting.
  • The key points are:
    • communicating the confidentiality of the diagnosis
    • communicating the reasons for testing and contact tracing
    • formulating expectations from treatment
    • promoting awareness of risk behaviours.
  • Counselling should also include discussion of the implications of STI testing (i.e. that testing does not prevent transmission). Emotional reactions can accompany a positive STI/HIV diagnosis with delayed reactions sometimes occurring several days after the consultation.

See also general principles.

Management of partners

All sexual partners of patients with gonorrhoea need to be traced, investigated and treated.

It is the responsibility of all health care providers, including doctors, to begin tracing sexual partners so that they can be assessed and treated.

This involves counselling to ensure that the patient understands the implications of infection transmission. Managing sexual partners may require referral to another practitioner or follow up by a public health unit.

Sexual partners of the index patient within the preceding three months should be assessed, and considered for treatment of gonorrhoea and chlamydia.

Contact tracing for gonorrhoea is a high priority. Untreated infections can lead to PID, epididymitis, disseminated infection, or neonatal conjunctivitis.

Special considerations

  • Period to trace is three months, consider up to six months, but this will depend on the sexual history and practical capacity to contact partners.
  • Gonorrhoea is easily transmitted by oral sex.
Follow up

To ensure continuity of care, record follow-up instructions in the patient's medical record.

Review all patients with gonorrhoea one to two weeks after treatment for follow-up and consideration of retesting, and to ensure that contact tracing has been completed. Consider retesting at 3 months for any reinfections. 

N. gonorrhoea may be detected up to 48 hours by culture and up to 7 days by NAAT following successful treatment.

Patients whose symptoms have not resolved one to two weeks after treatment should have repeat testing; if in doubt, seek advice from a specialist sexual health physician.

Patients whose symptoms have resolved should be prioritised for re-testing if their infection was acquired overseas or if they received a non-standard treatment.

If possible, review patients three months after exposure as this provides an opportunity to repeat blood tests for syphilis, HIV and HBV.

Public health issues

Penicillinase-producing N.gonorrhoea requires contact tracing be undertaken as a high priority to ensure that these organisms are eliminated as soon as possible from a community. Ceftriaxone-resistant N. gonorrhoea is a public health emergency and mandates immediate notification to the local PHU.

Contact tracing is important to prevent further transmission and reinfection. Always test for other STIs. If a child is diagnosed with gonorrhoea, issues of sexual abuse and/or sexual assault should be considered and mandatory notification of the infection forwarded to the local PHU.

Notification

This is a notifiable infection. Medical practitioners must complete the appropriate notification forms for all patients diagnosed with a notifiable STI/HIV, as soon as possible after confirmed diagnosis.

Epidemiological reports and real time notification data