Gonorrhoea

GC |

Overview

Cause

Neisseria gonorrhoeae, a Gram-negative intracellular diplococci (GNID) bacterium.

Clinical presentation

Male Female
Symptoms

Urethral discharge

Vaginal discharge

Dysuria

Dyspareunia with cervicitis

Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function
Conjunctivitis: purulent, sight threatening Conjunctivitis: purulent, sight threatening
Complications
Epididymo-orchitis: painful, red swollen testicle/s Pelvic inflammatory disease (PID), dyspareunia, intermenstrual bleeding, post-coital bleeding, discharge

Disseminated disease:

- macular rash that may include necrotic pustules

- septic arthritis

Disseminated disease:

- macular rash that may include necrotic pustules

- septic arthritis

Meningitis or endocarditis (rarely) Meningitis or endocarditis (rarely)
Prostatitis (very rarely)  

See STI Atlas for images.

Special considerations

Up to 80% of women and 10-15% of men have no genital symptoms and most people are asymptomatic or not obvious at other sites, especially the pharynx and rectum.

Diagnosis

ALWAYS test for culture before treating gonorrhoea to determine anti-microbial sensitivity and contribute to anti-microbial resistance surveillance.

Diagnosis in males
TestSite/SpecimenConsideration
NAAT

FPU

Always collect even if no discharge.

If MSM, also collect anal and phayrngeal swab for NAAT even if asymptomatic at these sites.

Culture

Urethral swab

Only required if discharge or other local symptoms present.

Gram stained urethral discharge may show gram negative intracellular diplococci but is not a sensitive test at non-urethral sites.

If MSM, also collect anal and pharyngeal swab even if asymptomatic at these sites.

NAAT +/- culture

Ano-rectal swab

In asymptomatic patients, a self-collected or practitioner -collected rectal swab for NAAT is sufficient.

However, if the patient has ano-rectal symptoms, best practice is for the clinician to examine with a proctoscope and collect swab for NAAT and culture.

NAAT +/- culture

Pharyngeal swab
 

Collect if MSM.

NAAT – Nucleic Acid Amplification Test
FPU – First pass urine
MSM – Men who have sex with men

 

Diagnosis in females
TestSite/SpecimenConsideration
NAAT +/- culture

Endocervical swab

If discharge/dysuria present.

NAAT +/- culture

Self-collected vaginal swab

If not examined.

NAAT

FPU

ONLY if endocervical swab/self-collected vaginal swab cannot be taken.

NAAT +/- culture

Pharyngeal swab

If patient has had oral sex.

NAAT +/- culture

Ano-rectal swab

If patent has had anal sex or has ano-rectal symptoms.

If patient declines anal examination, instruct self-collection or refer patient for testing to sexual health centre.

NAAT – Nucleic Acid Amplification Test
FPU – First pass urine
 

Specimen collection 

Clinician collected |
Self-collection

Investigations

Special considerations

If possible, culture samples should be obtained from genital and non-genital sites to determine antibiotic susceptibility before treating someone with a positive NAAT. 

Management

Principal Treatment Options
SituationRecommendedAlternative
Uncomplicated genital & ano-rectal infection

Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
PLUS
Azithromycin 1g PO, stat

Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions.

Seek local specialist advice.

Uncomplicated pharyngeal infection

Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine

PLUS

Azithromycin 2g PO, stat*

Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions.

Adult gonococcal conjunctivitis

Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
PLUS
Azithromycin 1g PO, stat

 Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions.
*This guideline was changed in December 2018: CLICK HERE for the rationale.


Treatment advice

Other immediate management

o   *This guideline was change in December 2018: click here for the rationale.

Special treatment situations

Special considerations

Consider seeking specialist advice before treating any complicated presentation.

SituationRecommended
Rectal coinfection

For rectal coinfection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine

PLUS


Doxycycline 100mg PO, BD 7 days if asymptomatic, but 21 days if symptomatic (see ano-rectal syndromes)

Pregnant women 
pregnancy
Same as principal treatment option.
Allergy to principal treatment choice

Seek specialist advice.

Regional/remote Amoxycillin 3g PO, stat
PLUS
Probenecid 1g PO, stat
PLUS
Azithromycin 1g PO, stat (when chlamydia not excluded).

If the infection is likely to have been acquired beyond local or other remote locations, use principal treatment option.

Contact tracing

See Australasian Contact Tracing Manual – Gonorrhoea for more information.

Follow up

Review in 1 week provides an opportunity to:

Test of Cure (TOC)

For pharyngeal, anal or cervical infection, TOC by Nucleic Acid Amplification Test (NAAT) should be performed 2 weeks after treatment is completed.

Retesting

Retest patients 3 months after exposure.

Special considerations

If TOC or retesting is positive, seek specialist advice.

Auditable outcomes

Last Updated: Saturday, 22 June 2019