There has been a major change in the treatment of GC (12/2020). The CDC no longer recommends dual therapy. The current guideline, summarized below, specifies a single agent approach.

CLINICAL ACTIONS:

Annual screening for gonococcal infection (GC) (N. gonorrhoeae) is recommended for all sexually active women aged <25 years and for older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection).

To diagnosis GC :

• Perform nucleic acid amplification testing (NAAT), which detects genetic material of N. gonorrhoeae
  • More sensitive than culture
  • Faster results than culture
  • Easy to obtain from a vaginal swab
  • Currently approved for genital (vaginal, endocervical) and urine samples
  • Can NOT determine antibiotic resistance

          OR

• Culture for N. gonorrhoeae
  • Requires endocervical swab, not vaginal
  • Available for rectal, oropharyngeal, and conjunctival gonococcal infection

NOTE: Obtain BOTH NAAT and culture in the case of treatment failure to determine bacterial susceptibility to antibiotics

SYNOPSIS:

Specific microbiologic diagnosis of infection with N. gonorrhoeae should be performed in all persons at risk for, or suspected to have, gonorrhea. A specific diagnosis can potentially reduce complications, reinfections, and transmission. The CDC no longer recommends combination therapy for uncomplicated GC

KEY POINTS:

For Uncomplicated Gonococcal Infections of the Cervix, Urethra and Rectum

• <150 kg (300 lb): Ceftriaxone 500 mg IM as a single dose
•  ≥150 kg (300 lb): 1 g of IM ceftriaxone
• If chlamydial infection has not been excluded
  • Treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days
  • During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

If Ceftriaxone is Unavailable

• Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose or
• Cefixime 800 mg orally as a single dose | If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days | During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

Uncomplicated Gonococcal Infections of the Pharynx

• <150 kg (300 lb): Ceftriaxone 500 mg IM as a single dose
•  ≥150 kg (300 lb): 1 g of IM ceftriaxone
• If chlamydial infection has not been excluded
  • Treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days
  • During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia

Note: No reliable alternative treatments are available for pharyngeal gonorrhea

Additional Notes

• Instruct patient to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated (7 days after receiving treatment and resolution of symptoms, if present)
• Test for other STIs, including chlamydia, syphilis and HIV
• A test-of-cure is not needed for persons who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens
• In the case of pharyngeal gonorrhea treated with an alternative regimen, the patient should return 14 days after treatment for a test-of cure using either culture or NAAT
  • If NAAT positive, do a confirmatory culture and antimicrobial susceptibility testing
• Retest after 3 months
  • Recurrence may not be treatment failure but rather reinfection
  • In States where legally allowed (see learn more below), consider Expedited Partner Therapy (EPT) which allows the patient herself to provide medications to her partner when there are limited public health services to treat a partner, or concern that the partner will not have access to treatment
• Treat women with HIV with the same recommended regimen
• Consult infectious disease specialist in case of allergies to cephalosporin

Diagnosis codes:

• Gonorrhea–nonpregnant A54.00 (PID A54.24, vaginal gonorrhea A54.02 other sites have other codes)
• Gonorrhea in pregnancy: 098.21X (1st trimester 098.211, 2nd trimester 098.212,
• 3rd trimester 098.213)
• Complicating childbirth 098.22
• In the puerperium: 098.23

Learn More – Primary Sources:

CDC: Gonococcal Infections in Adolescents and Adults

AACC: Chlamydia and Gonorrhea NAAT Screening Method Endorsed by CDC

CDC Gonorrhea Fact Sheet for your patients

Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020

Related ObG Topics:

Gonorrhea Treatment Pearls

Sexually Transmitted Diseases and Partner Notification

Chlamydia: CDC Recommendations for Diagnosis and Treatment

Pelvic Inflammatory Disease – CDC Treatment Guidelines

STD Screening in Pregnancy: CDC Recommendations

Screening & Treatment of Gynecologic infections in the HIV-Positive Woman

Screening for Sexually Transmitted Diseases – Who, When and How Often?