Gonorrhea and Disseminated Gonococcemia

Overview

Gonococcal infection may remain localized to one or several mucosal surfaces or may become bloodborne, causing a characteristic dermatitis-arthritis syndrome. The therapeutic strategy is to treat the pathogenic microorganism with the most appropriate antibiotic. Efficacy of treatment is dependent on the site of infection and the sexual exposures of the infected person. The sexual partners of persons with gonococcal infection are often asymptomatic carriers and must be referred for evaluation and treatment.

First Steps

1. For uncomplicated urethral and cervical infection: Intramuscular ceftriaxone 125 mg in one dose.
2. For anal gonorrhea in women, standard treatments are effective, but in men who have sex with men, ceftriaxone should be used (not the alternate treatments listed below).
3. Pharyngeal gonorrhea is harder to eradicate. Ceftriaxone 125 mg intramuscularly in a single dose is recommended.
4. For disseminated gonococcemia, salpingitis, prostatitis, and arthritis: Hospitalization and treatment with ceftriaxone 1 g intramuscularly or intravenously daily. Intravenous treatment is continued for 24-48 hours after improvement is noted, then the patient is switched to oral therapy with cefixime (or cefpodoxime) 400 mg orally twice daily to complete 1 week of treatment.
5. Evaluate the patient for other sexually transmitted diseases including HIV infection.
6. Perform a pregnancy test in women who potentially could be pregnant.
7. Treat the patient with urethral, cervical, rectal, and pharyngeal infection for coexistent chlamydial infection with doxycycline 100 mg twice daily for 7 days or azithromycin 1 g orally in a single dose.
8. Children with localized infection who weigh 45 kg or more are treated as adults. For children under 45 kg who have localized disease, ceftriaxone 125 mg intramuscularly in a single dose is recommended. For children of any weight with bacteremia and/or arthritis, treat with ceftriaxone 50 mg/kg intramuscularly or intravenously in a single dose daily for 7 days.

Alternative Steps

1. For urethral or cervical disease: Cefixime (or cefpodoxime) 400 mg orally in a single dose, ciprofloxacin 500 mg orally in a single dose, ofloxacin 400 mg orally in a single dose, levofloxacin 250 mg orally in a single dose, spectinomycin 2 g intramuscularly in a single dose (for patients allergic to both cephalosporins and quinolones). Ceftizoxime 500 mg intramuscularly, cefoxitin 2 g intramuscularly with probenecid 1 g orally, and cefotaxime 500 mg intramuscularly are alternative single-dose intramuscular treatments. (Men who have sex with men should not be treated with quinolones because of increasing resistance).
2. For pharyngeal disease: Nine regular strength tablets (trimethoprim 80 mg, sulfamethoxazole 400 mg) orally every day for 5 days. Repeat pharyngeal culture if symptoms persist.
3. For bacteremia (and arthritis): Cefotaxime 1 g intravenously every 8 hours, or ceftizoxime 1 g intravenously every 8 hours, or ciprofloxacin 400 mg intravenously every 12 hours, or ofloxacin 400 mg intravenously every 12 hours, or levofloxacin 250 mg intravenously daily, or spectinomycin 2 g intramuscularly every 12 hours (for patients allergic to both cephalosporin and quinolones).

Pitfalls

1. Gonococcal infection at all sites is a reportable disease. Notify your local health department if you make this diagnosis.
2. Evaluating for and treating other sexually transmitted infections is important. Do a complete examination.
3. Do not prescribe quinolones or tetracyclines for pregnant women.