Neisseria gonorrhoeae
(Redirected from Gonococcal)
Background
- Commonly known as gonorrhea or "GC"
- Fastidious gram-negative cocci
Clinical Features
Differential Diagnosis
Sexually transmitted diseases
- Chancroid
- Chlamydia trachomatis
- Granuloma inguinale
- Hepatitis B
- Herpes Simplex Virus-2
- HIV
- Human papillomavirus
- Lymphogranuloma venereum
- Neisseria gonorrhoeae
- Trichomonas
- Syphilis
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella (chickenpox)
- Smallpox
- Monkeypox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
- Contact dermatitis
- Herpes zoster (shingles)
- Dyshidrotic eczema
- Burn
- Dermatitis herpetiformis
- Erythema multiforme minor
- Poison Oak, Ivy, Sumac dermatitis
- Bullosis diabeticorum
- Bullous impetigo
- Folliculitis
Evaluation
Workup
- Dependent upon the infected organ
- PCR or culture on Thayer-Martin agar (most common)
Management
Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[1]
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
Standard
- Gonorrhea
- Ceftriaxone IM x 1 (500mg if <150kg, 1g if ≥150kg)
- Chlamydia
- Nonpregnant: Doxycycline 100 mg PO BID x 7 days
- Pregnant: Azithromycin 1 g PO x 1
Ceftriaxone contraindicated
- Gonorrhea
- Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
- Cefixime 800 mg PO x 1
- Chlamydia^
- Nonpregnant: doxycycline 100 mg PO BID x 7 days
- Pregnant: azithromycin 1 g PO x 1
^Additional chlamydia coverage only needed if treated with cefixime only
Partner Treatment
- Gonorrhea
- Cefixime 800mg PO x 1
- Chlamydia
- Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
- Pregnant: azithromycin 1g PO x 1
Presumed GC/chlamydia of the pharynx (uncomplicated)[2]
Standard
Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.
- Gonorrhea
- Ceftriaxone IM x 1
- 500 mg, if weight <150 kg
- 1 g, if weight ≥150 kg
- Ceftriaxone IM x 1
- Chlamydia
- Nonpregnant: doxycycline 100 mg PO BID x 7 days
- Pregnant: azithromycin 1 g PO x 1
Ceftriaxone contraindicated
- No reliable alternative treatments are available for pharyngeal gonorrhea
- For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended.[3]
- For persons with an anaphylactic or other severe reaction (e.g. Stevens Johnson syndrome) to ceftriaxone, consult an infectious disease specialist for an alternative treatment recommendation.
Test of Cure
CDC recommends a repeat culture be obtained 7-14 days after initial treatment only in persons with pharyngeal gonorrhea.
Specific Disease Processes
- Cervicitis
- Conjunctivitis
- Epididymitis
- Infectious tenosynovitis
- Orchitis
- Pelvic inflammatory disease (PID)
- Proctitis
- Septic arthritis
- Urethritis
Antibiotic Dosing
Adult
- Gentamicin 240mg IM x 1
Pediatric
- Doxycycline >8 years old/>45 kg; 100mg PO q12h x 7 days; Not first line- use with ceftriaxone
- Cefuroxime 1000mg PO x 1
Antibiotic Sensitivities[4]
| Category | Antibiotic | N. gonorrhoeae |
| Penicillins | Penicillin G | 0 |
| Penicillin V | 0 | |
| Anti-Staphylocccal Penicillins | Methicillin | 0 |
| Nafcillin/Oxacillin | 0 | |
| Dicloxacillin | 0 | |
| Amino-Penicillins | AMP/Amox | 0 |
| Amox-Clav | + | |
| AMP-Sulb | + | |
| Anti-Pseudomonal Penicillins | Ticar-Clav | + |
| Pip-Tazo | + | |
| Carbapenems | Doripenem | + |
| Ertapenem | + | |
| Imipenem | + | |
| Meropenem | + | |
| Aztreonam | + | |
| Fluroquinolones | Ciprofloxacin | +* |
| Ofloxacin | +* | |
| Levofloxacin | +* | |
| Moxifloxacin | +* | |
| Gemifloxacin | ||
| Gatifloxacin | +* | |
| 1st G Cephalo | Cefazolin | + |
| 2nd G Cephalo | Cefotetan | +/- |
| Cefoxitin | +/- | |
| Cefuroxime | +/- | |
| 3rd/4th G Cephalo | Cefotaxime | +/- |
| Cefizoxime | +/- | |
| CefTRIAXone | + | |
| Ceftaroline | + | |
| CefTAZidime | +/- | |
| Cefepime | + | |
| Oral 1st G Cephalo | Cefadroxil | 0 |
| Cephalexin | 0 | |
| Oral 2nd G Cephalo | Cefaclor | +/- |
| Cefproxil | +/- | |
| Cefuroxime | +/- | |
| Oral 3rd G Cephalo | Cefixime | + |
| Ceftibuten | +/- | |
| Cefpodox/ Cefdinir/ Cefditoren | + | |
| Aminoglycosides | Gentamicin | 0 |
| Tobramycin | 0 | |
| Amikacin | 0 | |
| Chloramphenicol | + | |
| Clindamycin | 0 | |
| Macrolides | Erythromycin | +/- |
| Azithromycin | +/- | |
| Clarithromycin | +/- | |
| Ketolide | Telithromycin | + |
| Tetracyclines | Doxycycline | +/- |
| Minocycline | +/- | |
| Glycylcycline | Tigecycline | + |
| Sulfonamides | TMP-SMX | +/- |
| Urinary Agents | Nitrofurantoin | + |
| Fosfomycin | + | |
| Other | Rifampin | + |
| Metronidazole | 0 | |
| Quinupristin-dalfoppristin | + | |
| Linezolid | ||
| Daptomycin | 0 | |
| Colistimethate | 0 | |
| Telavancin | 0 | |
| Vancomycin | 0 |
Key
- S susceptible/sensitive (usually)
- I intermediate (variably susceptible/resistant)
- R resistant (or not effective clinically)
- S+ synergistic with cell wall antibiotics
- U sensitive for UTI only (non systemic infection)
- X1 no data
- X2 active in vitro, but not used clinically
- X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
- X4 active in vitro, but not clinically effective for strep pneumonia
Table Overview
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References
- ↑ Cyr SS et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑ Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
- ↑ CDC. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2015;64(No. RR-3). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm.
- ↑ Sanford Guide to Antimicrobial Therapy 2010
Disposition
- Depends on clinical features/presentation