Gonococcal infection in adolescents and adults

In the US, the number of new cases of infection caused by N. Gonorrhoeae is estimated at 600,000 per year. In most cases, infection in men is accompanied by the appearance of symptoms, which causes them to begin treatment quickly enough to prevent serious complications, but not quickly enough to prevent transmission of infection to others. In women, in most cases, the infection is asymptomatic until such complications as PID develop. PID, regardless of the presence or absence of symptoms, can lead to disruption of patency of the fallopian tubes, which, in turn, leads to the development of infertility or ectopic pregnancy. Because gonococcal infection in women is often asymptomatic, the primary measure of gonorrhea control in the US is screening of women belonging to high-risk groups.

[1], [2], [3], [4], [5], [6],

Uncomplicated gonococcal infection

Recommended schemes

• Cefixime 400 mg orally, once,
• or Ceftriaxone 125 mg IM once,
• or Ciprofloxacin 500 mg orally once,
• or Ofloxacin 400 mg orally once,
• plus Azithromycin 1 g orally once
• or Doxycycline 100 mg orally 2 times a day for 7 days.

The spectrum of antimicrobial action of cefixime is similar to that of ceftriaxone, however the oral dosage of cefixime 400 mg does not provide such a constant and high bactericidal level of the drug in the blood as 125 mg of ceftriaxna. The published data from clinical trials show that a dose of 400 mg cures 97.1% of uncomplicated urogenital and anorectal infections. The advantage of cefixime is that it can be used orally.

A single dose of ceftriaxone 125 mg provides a constant high bactericidal level of the drug in the blood. Extensive clinical experience shows that it is safe and effective for the treatment of uncomplicated gonorrhea and heals 99.1% of cases of uncomplicated urogenital and anorectal infections submitted to clinical trials.

Ciprofloxacin is very active against most strains of N. Gonorrhoeae and at a dose of 500 mg provides a constant bactericidal level in the blood, curing 99.8% of uncomplicated urogenital and anorectal infections according to published clinical trials. Ciprofloxacin is safe, relatively inexpensive and can be used orally.

Ofloxacin is also very active against most strains of N. Gonorrhoeae and has favorable pharmacokinetics. The oral dose of 400 mg effectively cures in 98.4% of cases of uncomplicated urogenital and anorectal infections.

Uncomplicated gonococcal laryngeal infection

Gonococcal infection of the larynx is much harder to cure than the infection of the urogenital and anogenital areas. Several recommended regimens are effective in more than 90% of cases.

Recommended schemes

• Ceftriaxone 125 mg IM once,
• or Ciprofpoxacin 500 mg orally once,
• or Ofloxacin 400 mg orally once,
• plus Azithromycin 1 g orally once
• or Doxycycline 100 mg orally 2 times a day for 7 days.

Gonococcal conjunctivitis

In recent years, the results of only one study devoted to the treatment of gonococcal conjunctivitis in adults, which was conducted in North America, have been published. In this study, good results were achieved with cefriaxone 1 g / m in 12 of 12 patients.

Treatment

A single dose of ceftriaxone 1 g should be given in / m; In addition, the affected eye is washed once with physiological saline.

Management of sexual partners

Patients should be instructed on the notification of sexual partners about the need for examination and treatment (see Uncomplicated gonococcal infection, Management of sexual partners).

[7], [8], [9],

Disseminated gonococcal infection

Disseminated gonococcal infection (DGI) is a consequence of gonococcal bacteremia, often manifested in the form of petechial or pustular eruptions, asymmetric arthralgia, tendosynovitis, or septic arthritis. Sometimes the infection is complicated by perihepatitis and rarely by endocarditis or meningitis. Strains N. Gonorrhoeae, causing disseminated gonococcal infection, tend to give a slight inflammation in the genital area. In the last decade, such strains have rarely been isolated in the US

Recently, there has been no published data on the treatment of disseminated gonococcal infection in North America.

Treatment

For initial therapy, hospitalization is recommended, especially when there is no certainty that the patient will complete the course of treatment, as well as with an unclear diagnosis, the presence of purulent effusion in the joints or other complications. Patients should be examined for endocarditis and meningitis. Patients receiving treatment for disseminated gonococcal infection should also be treated prophylactically for Chlamydia infection.

Recommended initial scheme

Ceftriaxone 1 g IM or IV every 24 hours.

Alternative Initial Schemes

Ceftriaxone 1 g IV every 8 hours,

Or Ceftizoxime 1 g IV every 8 hours,

Or For persons with allergy to beta-lactam drugs:

Ciprofloxacin 500 mg IV every 12 hours

Or Ofloxacin 400 mg IV every 12 hours

Or Spectinomycin 2 g / m every 12 hours.

Treatment for all these schemes should continue for 2,448 hours after the onset of improvement; then treatment can be performed according to one of the following schemes (total duration of treatment is 1 week):

Cefixime 400 mg orally 2 times a day,

Or Ciprofloxacin 500 mg orally 2 times a day.

Or Ofloxacin 400 mg orally 2 times a day

Management of sexual partners

Gonococcal infection in sexual partners of people with disseminated gonococcal infection often occurs asymptomatically. As with an uncomplicated infection, patients should be instructed regarding the notification of sexual partners and their involvement in examination and treatment (see Uncomplicated gonococcal infection, Management of sexual partners).

[10], [11], [12], [13], [14]

Gonococcal meningitis and endocarditis

Recommended initial scheme

Ceftriaxone 1-2 g IV every 12 hours.

Treatment of meningitis should last 10-14 days, and endocarditis - at least 4 weeks. Treatment of complicated DGI should be conducted with the participation of experts.

Management of sexual partners

As with an uncomplicated infection, patients should be instructed on notification of sexual partners and their involvement for examination and treatment.

Simultaneous treatment of gonorrhea and chlamydial infection

Observations show that C. Trachomatis is often detected in persons infected with N. Gonorrhoeae, therefore, patients receiving treatment for gonorrhea should also be prescribed drugs effective against uncomplicated genital chlamydial infection. Carrying out therapy directed against both pathogens without preliminary testing for chlamydia can be clearly beneficial in populations where chlamydial infection in 20-40% accompanies gonococcal infection, since treatment of chlamydia costs significantly less (from $ 0.50 to $ 1.50 per doxycycline) for compared with the cost of the survey. Some experts believe that the routine use of this method of treatment leads to a significant decrease in the prevalence of Chlamydia infection. Since most strains of gonococci in the United States are sensitive to doxycycline and azithromycin, their simultaneous use may interfere with the development of antimicrobial resistance of N. Gonorrhoeae.

Since the therapy directed against both pathogens began to apply, the prevalence of chlamydial infection has decreased in some populations, and chlamydial infection tests have become more sensitive and are used much more widely. Where the prevalence of mixed infection is low, some clinicians may prefer testing for chlamydia rather than co-treatment. However, this method of treatment is indicated for patients who may not return for test results.

Stability of N. Gonorrhoeae to quinolones

Cases of gonorrhea caused by quinolone-resistant strains are sporadic in many parts of the world, including North America, and are beginning to spread widely in the Asian regions. By February 1997 in the US, quinolone-resistant strains of gonococci were still rare. Less than 0.05% of 4,639 isolates isolated from the GISP program in 1996 had a minimal inhibitory concentration (MIC) of ciprofloxacin> 1.0 mg / ml. Isolates were obtained from 26 cities and accounted for approximately 1.3% of all strains isolated from men with diagnosed gonococcal infection in the United States. Since quinolone resistant strains account for less than 1% of all N. Gonorrhoeae strains isolated in each of the 26 cities, fluoroquinolones can be recommended for use. However, the resistance of gonococcus to quinolones is likely to increase.

Alternative schemes

Spectinomycin 2 g IM once. Spectinomycin is expensive and should be used in injections. However, it is an effective drug and, according to published clinical trials, cures 2% of uncomplicated urogenital and anorectal infections. Spectinomycin remains the drug of choice in the treatment of patients who tolerate neither cephalosporins nor quinolones.

Single-dose cefalosporin treatment regimens that are effective in uncomplicated genital or anal gonorrhea, except ceftriaxone (125 mg w / m) and cefixime (400 mg orally), include: a) ceftizoxime 500 mg IM once, b) cefotaxime 500 mg w / m once, c) cefotetan 1 g IM once, and d) cefoxitin 1 g IM once with probenecid 1 g orally. None of these injectable cephalosporins has any advantages over ceftriaxone and experience with their clinical use in uncomplicated gonorrhea is less.

Single-dose regimens for treatment with quinolones include: Enoxacin 400 mg orally; Lomefloxacin 400 mg orally and norfloxacin 800 mg orally. It is shown that they are safe and effective in the treatment of uncomplicated gonorrhea, but they do not have any advantages in comparison with ciprof-loxacin in a dose of 500 mg or ofloxacin in a dose of 400 mg.

There are many other antimicrobial agents that are active against N. Gonorrhoeae, but the task of this manual is not to publish a list of all effective treatment regimens.

Azithromycin, 2 g orally, is effective against uncomplicated gonococcal infection, but is expensive and too often causes gastrointestinal disorders so that it can be recommended for the treatment of gonorrhea. When administered orally in a dose of 1 g, acitromycin is not effective enough, only 93% of cases cure, according to published studies.

[15], [16], [17], [18], [19], [20],

Follow-up

Individuals with uncomplicated gonorrhea treated with any of the schemes recommended by this manual do not need to control cure. If after the end of treatment the symptoms do not disappear, it is necessary to conduct a culture test on N. Gonorrhoeae, to determine the resistance of all isolated strains of gonococci to antimicrobial agents. Infections detected after treatment with one of the recommended regimens are usually a consequence of reinfection, rather than a lack of treatment effect, which indicates the need for improved notification of sexual partners and patient education. Chronic urethritis, cervicitis or proctitis can also be caused by C. Trachomatis or other microorganisms.

[21], [22],

Management of sexual partners

Patients should be instructed about the need to notify sexual partners and involve them for examination and treatment. All sexual partners of patients with gonorrhea should be examined and treated against gonorrhea and chlamydia if the last sexual contact occurred within 60 days of the onset of the patient's symptoms or diagnosis. If the last sexual contact of the patient was more than 60 days before the onset of symptoms or diagnosis, his last sexual partner should be treated. Patients should be instructed to abstain from sexual intercourse until the treatment is completed and the patient and his partner (s) have no symptoms.

Special Remarks

Allergy, intolerance or side effects

Patients with intolerance to cephalosporins and quinolones should be treated with spectinomycin. However, since the efficacy of spectinomycin in the treatment of pharyngeal infection is only shown in 52% of cases, patients who suspect or have a pharyngeal infection should undergo pharyngeal culture 3-5 days after treatment to confirm the disappearance of the pathogen.

[23], [24]

Pregnancy

Pregnant women should not prescribe quinolones or tetracyclines. Pregnant, infected N. Gonorrhoeae should be treated with cephalosporins according to recommended or alternative regimens. For women with intolerance to cephalosporins, a single I / m injection of 2 g of spectinomycin is recommended.

Erythromycin or amoxicillin are the drugs of choice if a chlamydial infection is suspected or diagnosed during pregnancy (see Chlamydia infection).

HIV infection

Persons with HIV infection and gonococcal infection should receive the same treatment as patients without HIV infection.