Gonorrhea and Chlamydia

Background

Gonorrhea, caused by Neisseria gonorrhoeae (GC), and chlamydia, caused by Chlamydia trachomatis (CT), are sexually transmitted diseases (STDs). These infections may be transmitted during oral, vaginal, or anal sex; they also can be transmitted from a mother to her baby during delivery and cause significant illness in the infant.

Both organisms can infect the urethra, oropharynx, and rectum in women and men; the epididymis in men; and the cervix, uterus, and fallopian tubes in women. Untreated GC or CT infection in women may lead to pelvic inflammatory disease (PID), which can cause chronic pelvic pain and scarring of the fallopian tubes that results in infertility or ectopic pregnancy (tubal pregnancy). N. gonorrhoeae can cause disseminated infection involving the skin, joints, and other systems. Infection with GC or CT may facilitate transmission of HIV to HIV-uninfected sex partners.

Certain strains of CT can cause lymphogranuloma venereum (LGV). This infection is common in parts of Africa, India, Southeast Asia, and the Caribbean. While relatively uncommon in the United States, outbreaks among men who have sex with men (MSM) have been reported in recent years. LGV may cause genital ulcers, followed by inguinal adenopathy; it also can cause proctocolitis with anorectal discharge, tenesmus, and pain.

Patients with symptoms of gonorrhea or chlamydia should be evaluated and treated as indicated below. Although GC or CT urethral infections in men may cause symptoms, infection in women and oral or rectal infections in men often cause no symptoms. Thus, sexually active individuals at risk of GC and CT exposure should receive regular screening for these infections as well as for syphilis and other STDs; for most patients, this should be at least annually, and every 3-6 months for persons at higher risk (see chapter Initial and Interim Laboratory and Other Tests).

S: Subjective

Symptoms will depend on the site of infection (e.g., oropharynx, urethra, cervix, rectum). Symptoms are not present in many patients, thus it is important to screen all patients at risk of STDs.

If symptoms are present, women may notice the following (depending on site of infection):

• Vaginal discharge
• Pain with sexual intercourse
• Pain or burning on urination
• Abdominal or pelvic pain
• Sore throat
• Rectal discharge
• Anal discomfort or tenesmus

If symptoms are present, men may notice the following (depending on site of infection):

• Pain or burning on urination
• Urethral discharge
• Testicular tenderness or pain
• Sore throat
• Rectal discharge
• Anal discomfort or tenesmus

During the history, ask the patient about the following:

• Any of the symptoms listed above, and their duration
• Previous diagnosis of GC, CT, or other STD
• New sex partner(s); number and gender of partners
• Unprotected sex (oral, vaginal, anal; receptive or insertive)
• For women: last menstrual period, and whether the patient could be pregnant; use of an intrauterine device

O: Objective

Physical Examination

During the physical examination, check for fever and document other vital signs.

For women, focus the physical examination on the mouth, abdomen, and pelvis. Inspect the oropharynx for discharge and lesions; check the abdomen for bowel sounds, distention, rebound, guarding, masses, and suprapubic or costovertebral angle tenderness; perform a complete genital and vaginal examination for abnormal discharge or bleeding; check for uterine, adnexal, or cervical motion tenderness; and search for pelvic masses or adnexal enlargement. Check the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. Check the skin for rashes and lesions.

For men, focus the physical examination on the mouth, genitals, and anus/rectum. Check the oropharynx for lesions, the urethra for discharge, the external genitalia for tenderness, masses, or lesions, and the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. Check the skin for rashes and lesions.

A: Assessment

A partial differential diagnosis includes the following:

• Urinary tract infection
• Dysmenorrhea
• Appendicitis
• Cystitis
• Proctitis
• PID
• Irritable bowel syndrome
• Pyelonephritis

P: Plan

Diagnostic Evaluation

Test for oral, urethral, or anorectal infection, according to symptoms and anatomic site(s) of possible exposures. Perform testing for both gonorrhea and chlamydia (testing for pharyngeal CT infection generally is not recommended although the CT pharyngeal test often accompanies the GC pharyngeal nucleic acid amplification test [NAAT]). The availability of the various testing methods varies according to the specific clinic site. Consider the following:

• NAAT: urine specimens (first stream) and urethral (men), vaginal, and endocervical swab specimens; also used with pharyngeal and rectal swab specimens (laboratory must meet CLIA specifications and establish validity in nongenital specimens); recommended unless GC antibiotic resistance is suspected
• GC culture (oropharynx, endocervix, urethra, rectum) -- consider especially if antibiotic resistance is suspected
• Gram stain of urethral discharge for evidence of GC
• Serologic tests (complement fixation test) if LGV is suspected

Treatment

Treatments for gonorrhea and chlamydia are indicated below. Fluoroquinolone-resistant GC is widespread in the United States and worldwide. Thus, the U.S. Centers for Disease Control and Prevention (CDC) recommends that fluoroquinolones not be used for treatment of GC. Similarly, resistance of GC to cephalosporins is emerging, though third-generation cephalosporins are effective against most GC strains in the United States and remain the only recommended treatment for GC. GC strains with decreased susceptibility to azithromycin also have been reported, and azithromycin should be used to treat GC only for select patients in whom treatment with a cephalosporin should be avoided.

Adherence is essential for treatment success. Single-dose treatments maximize the likelihood of adherence and are preferred. Other considerations in choosing the treatment include antibiotic resistance, cost, allergies, and pregnancy. For further information, see the CDC STD treatment guidelines (see "References," below); treatments should be given in accordance with these guidelines.

Any sex partners within the past 60 days, or the most recent sex partner from >60 days before diagnosis, also should receive treatment. Patients should abstain from sexual activity for 7 days after a single-dose treatment or until a 7-day treatment course is completed. Reinfection with GC or CT is likely if reexposure occurs; patients with either GC or CT should be rescreened 3 months after treatment.

Treatment of Gonorrhea

Treatment options include the following (see the full CDC STD treatment guidelines, referenced below); the current guidelines emphasize that dual therapy for GC should be given, with ceftriaxone plus either azithromycin or doxycycline. Ceftriaxone is the recommended cephalosporin for GC infection at any anatomic site. Coadministration of azithromycin or doxycycline is intended to improve the likelihood of cure and may decrease the risk of emergent cephalosporin resistance; it should be given, even if testing for CT is negative.

Recommended regimen

• Ceftriaxone 250 mg IM injection in a single dose, plus azithromycin 1 g PO in a single dose or doxycycline 100 mg PO BID for 7 days

Alternative regimens*

• Cefixime 400 mg PO in a single dose (tablet or oral suspension), plus azithromycin or doxycycline, as above
• Spectinomycin 2 g IM injection in a single dose (currently not available in the United States), plus azithromycin or doxycycline, as above
• Azithromycin 2 g PO in a single dose

* If an alternative regimen is used, a test of cure (TOC) should be done in 1 week: GC culture (preferred) or NAAT. A positive NAAT result should be followed by confirmatory culture and antimicrobial susceptibility testing. Possible cephalosporin treatment failures should be reported immediately to the local or state health department.

If penicillin or cephalosporin allergy:

• Cephalosporins are contraindicated only in patients with a history of severe reaction to penicillin.
• Consultation with an infectious disease specialist is recommended.
• Spectinomycin can be used for urogenital or rectal infection (inadequate for pharyngeal GC), with TOC, as above.
• Azithromycin 2 g PO, with TOC, as above.
• Consider cephalosporin treatment following desensitization.

Note: Fluoroquinolones are not recommended for treatment of gonococcal infection because of widespread resistance in the United States.

Please see full CDC STD treatment guidelines regarding treatment of PID, epididymitis, and disseminated gonococcal infection.

Treatment of Chlamydia

(See the full CDC STD treatment guidelines, referenced below.)

Recommended regimens

• Azithromycin 1 g PO in a single dose
• Doxycycline 100 mg PO BID for 7 days

Alternative regimens

• Erythromycin base 500 mg PO QID for 7 days
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days
• Levofloxacin 500 mg PO once daily for 7 days (see Note above)
• Ofloxacin 300 mg PO BID for 7 days (see Note above)

Treatment of LGV

Recommended regimens

• Doxycycline 100 mg PO BID for 21 days

Alternative regimens

• Erythromycin base 500 mg PO QID for 21 days
• Azithromycin 1 g PO once weekly for 3 weeks (limited data)

For recent sex partners (within 60 days before the onset of patient's symptoms), test for urethral or cervical CT, treat with azithromycin 1 g PO in a single dose or doxycycline 100 mg PO BID for 7 days.

Treatment During Pregnancy

Use of fluoroquinolones and tetracyclines should be avoided during pregnancy.

Recommended GC regimens

• Ceftriaxone 250 mg IM + azithromycin 1 g PO in a single dose

Recommended CT regimens

• Azithromycin 1 g PO in a single dose
• Amoxicillin 500 mg PO TID for 7 days

Alternative CT regimens

• Erythromycin base 500 mg PO QID for 7 days
• Erythromycin base 250 mg PO QID for 14 days
• Erythromycin ethylsuccinate 800 mg PO QID for 7 days
• Erythromycin ethylsuccinate 400 mg PO QID for 14 days

Follow-Up

• For both GC and CT, evaluate the patient's sex partners; treat them empirically if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms. (Some clinics provide empiric treatment for partners via "partner packs," or a treatment regimen that the patient takes to the partner(s); this approach may be effective, particularly for CT, if the partner(s) is/are unlikely to come to the clinic for evaluation and treatment.
• Most recurrent infections come from sex partners who were not treated.
• The CDC recommends rescreening all patients 3 months after GC or CT treatment (for possible reinfection).
• For pregnant women with CT, retest (by NAAT) 3 weeks after completion of treatment.
• If symptoms persist, evaluate for the possibility of reinfection, treatment failure, or a different cause of symptoms. If treatment failure is suspected, perform culture and antimicrobial sensitivity testing.
• Screen for GC, CT, chlamydia, syphilis, and other STDs at regular intervals according to the patient's risk factors. The sites of sampling (e.g., pharynx, urethra, endocervix, anus/rectum) will be determined according to the patient's sexual exposures.
• Evaluate each patient's sexual practices with regard to the risk of acquiring STDs and of transmitting HIV; work with the patient to reduce sexual risks.

Patient Education

• Instruct patients to take all of their medications. Advise patients to take medications with food if they are nauseated and to call or return to clinic right away if they experience vomiting or are unable to take their medications.
• Sex partners from the previous 60 days need to be tested for sexually transmitted pathogens, and treated as soon as possible with a regimen effective against GC and CT, even if they have no symptoms. Advise patients to inform their partner(s) that they need to be tested and treated. Otherwise, patients may be reinfected.
• Advise patients to avoid sexual contact until the infection has been cured (in themselves and in their partners) at least 7 days.
• Provide education about sexual risk reduction. Instruct patients to use condoms with every sexual contact to prevent reinfection with GC or CT, to prevent other STDs, and to prevent transmission of HIV to sex partners.

References

• Bolan GA, Sparling PF, Wasserheit JN. The emerging threat of untreatable gonococcal infection. N Engl J Med. 2012 Feb 9;366(6):485-7.
• Centers for Disease Control and Prevention. Gonorrhea -- CDC Fact Sheet.
• Centers for Disease Control and Prevention. Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR. 2004 Oct 29;53(42):985-8.
• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010 Dec 17; 59 (No. RR-12):1-110.
• Centers for Disease Control and Prevention. Cephalosporin susceptibility among Neisseria gonorrhoeae isolates -- United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):873-7.