Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrhoeae (N. gonorrhoeae), a Gram-negative intracellular diplococcus.

Gonorrhoea is asymptomatic in 80% of women and 10% to 15% of men so testing is important irrespective of symptoms.

Gonorrhoea is an STI characterised by one or more of the following:

• Urethral discharge (urethritis) and/or burning sensation (dysuria)
• Cervical discharge (cervicitis) and/or intermenstrual or post-coital bleeding
• Anorectal infection (proctitis) with discharge, painful defecation, disturbed bowel function or irritation 
• Pharyngeal infection
• Pelvic inflammatory disease (PID) and associated dyspareunia (pain during vaginal intercourse)
• Prostatitis (very rarely)
• Epididymitis
• Conjunctivitis
• Skin lesions

Rarely

• Disseminated disease is uncommon but serious; it can present as septic arthritis, meningitis, endocarditis, sepsis, and macular rash that may include necrotic pustules. 

STI Atlas (external site)

A definitive diagnosis of gonorrhoea is established by detecting N. gonorrhoeae in a clinical specimen by culture or by NAAT. Culture swabs are recommended whenever possible so that antimicrobial susceptibilities can be obtained. Serious resistance to gonorrhoea is emerging with few treatment options in the future being available, and antimicrobial surveillance is a vital public health measure.

A presumptive diagnosis of gonorrhoea is achieved by:

• Demonstrating at least two Gram-negative intracellular diplococci in a smear made from a male urethral swab. Absence of neutrophils or gonococci on Gram stain does not exclude gonorrhoea.
• Demonstrating Gram-negative intracellular diplococci in a smear from a patient with clinical features compatible with gonococcal infection.

Men

• Detecting Gram-negative intracellular diplococci in a urethral smear is a reliable indicator of gonorrhoea, but the absence of diplococci does not exclude the diagnosis. For these reasons, always collect samples for culture and NAAT.
• If there is no discharge (an unusual situation in male urethral gonorrhoea), collect FVU for NAAT.
• If the patient has had receptive anal sex, oro-anal sex, rimming or fingering, and no anal symptoms: Patients can be instructed how to take two blind ano-rectalal swabs himself or herself. Refer to the STI self-testing card (PDF 716KB) for instructions. However, if the patient presents with anal symptoms, collect a dry swab of the discharge for NAAT (no transport medium) and a second swab under direct vision of the rectal mucosa via a proctoscope and transport in charcoal (black) or non-charcoal (clear) agar gel transport medium for culture and sensitivity.
• If the patient has had receptive oral sex, and no oral symptoms, take a throat swab for NAAT (no transport medium). 

Women

• If cervical pus is present or the cervix is inflamed, swab under direct vision of the cervix via a vaginal speculum and transport in charcoal (black) or non-charcoal (clear) agar gel transport medium for culture and sensitivity, then collect 2 dry swabs of the discharge for NAAT (no transport medium) – one for chlamydia/gonorrhoea and another one for M. Genitalium. Endocervical swabs are essential for culture and high vaginal swabs are not adequate for culture. If the patient has had a hysterectomy, urine for NAAT must be collected.

• If there is no discharge, self-obtained vaginal swabs are the preferred specimen. If the patient is examined take an endocervical swab for NAAT (no transport medium). A urine specimen is acceptable if a woman declines to give either a vaginal or endocervical swab but will miss some cervical infections.

• Diagnosis and treatment of infected patients prevents ongoing/further transmission to sex partners and, for infected pregnant women, may prevent transmission of gonorrhoea to infants during birth.

The treatment of gonorrhoea in WA must be guided by the current antimicrobial susceptibility profile.

Treating uncomplicated gonorrhoea

Adults

Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to this treatment. 

• Ceftriaxone 500 mg in 2 mL 1% lignocaine, given by intramuscular injection

        AND

• Azithromycin 1 g (orally), given together as a single treatment

Pregnancy

Treatment in pregnancy is the same as non-pregnant individuals 

• Australian categorisation system for prescribing medicines in pregnancy (external site).

Children

• Ceftriaxone 50 mg/kg (maximum 500 mg), giver by intramuscular injection (using the adult dilution)

        AND

• Azithromycin 20 mg/kg (to a maximum of 1 g) (oral tablet or syrup), given together as a single treatment

Uncomplicated gonorrhoea excludes:

• PID
• Epididymitis
• Ophthalmic lesions
• Prostatitis
• Arthritis
• Disseminated infections.

For treatment of adults and mature minors (aged 14 years or older) with uncomplicated gonorrhoea under a Structured Administration and Supply Arrangement, see Structured Administration and Supply Arrangement - CEO of Health SASA. This is suitable for use by Registered Nurses and Aboriginal Health Practitioners employed by a health service operated or managed by a Health Service Provider of the WA Department of Health, or contracted entity.

Chlamydia co-infection

The chlamydia co-infection rate among patients with heterosexually acquired gonorrhoea is about 40%

Because of the high risk of co-infection, treat all symptomatic patients who are suspected to have gonorrhoea, for chlamydia as well.

For suspected urethral and cervical infections, azithromycin 1mg stat (with ceftriaxone 500mg IMI as for gonorrhoea infection) will be adequate. 

For rectal co-infection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:

• Ceftriaxone 500mg in 2mL 1% lignocaine, given by intramuscular injection

• Doxycycline 100mg orally, twice daily, for 7 days if asymptomatic, but 21 days if symptomatic (internationally recognised treatment)

• Azithromycin 1g orally, as a single dose, and repeat in 1 week

Treating gonorrhoea in other clinical situations

Allergy to penicillin

Delayed type hypersensitivity (rash)

• Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly, (Note: should not be used when the allergy to penicillin is recorded as severe and/or hypersensitivity is immediate)

AND

• Azithromycin 1 g (orally), as a single dose, given together as a single treatment

Severe or immediate type hypersensitivity (anaphylaxis, Stevens Johnson syndrome, toxic epidermal necrolysis)

• Azithromycin 2 g orally, as a single dose - may cause gastro-intestinal intolerance

• Seek advice from a sexual health specialist

Regarding ciprofloxacin

• ciprofloxacin should no longer be used for empirical treatment due to increasing resistance profiles. It should only be used when culture has demonstrated ciprofloxacin susceptibility.
• ciprofloxacin should not be used in children under 12 years or pregnant women.

Pharyngeal gonorrhoea

Adults

• Ceftriaxone 500 mg in 2 mL 1% lignocaine give by intramuscular injection

AND

• Azithromycin 2 g orally, as a single dose, given together as a single treatment

Children

• Ceftriaxone 50 mg/kg (maximum 500 mg) given by intramuscular injection (using the adult dilution)

AND

• Azithromycin 20 mg/kg to a maximum of 1g (oral tablet or syrup), as a single dose, given together as a single treatment

Special considerations

• amoxycillin monotherapy should not be used in either adults or children for gonococcal pharyngeal infections because of the difficulty in achieving an adequate concentration of antibiotic in tissues and cells.

Anorectal gonorrhoea 

• Ceftriaxone 500 mg in 2 mL 1% lignocaine given by intramuscular injection

Counselling is important in managing STIs/HIV and should be considered at every contact with the patient.

As a minimum, consider counselling at the first presentation and subsequently during treatment and follow-up.

• Counselling is an opportunity to educate and support the patient in prevention strategies. This should be done in a confidential setting.
• The key points are:
  • communicating the confidentiality of the diagnosis
  • communicating the reasons for testing and contact tracing
  • formulating expectations from treatment
  • promoting awareness of risk behaviours.

Patients should be advised no sexual contact for 7 days after completion of treatment and to avoid sexual contact with any partners from the last 6 months until 7 days after they have been tested and treated.

See also general principles.

All sexual partners of patients with gonorrhoea need to be traced, investigated and treated.

It is the responsibility of all health care providers, including doctors, to begin tracing sexual partners so that they can be assessed and treated. Partners should be advised no sexual contact for 7 days after completion of treatment and to avoid sexual contact with any other partners from the last 6 months until 7 days after they have been tested and treated

Special considerations

• Period to trace is a minimum of 2 months.
• Gonorrhoea is easily transmitted by oral sex.

For treatment of adults and mature minors (aged 14 years or older) with uncomplicated gonorrhoea under a Structured Administration and Supply Arrangement, see Structured Administration and Supply Arrangement - CEO of Health SASA. This is suitable for use by Registered Nurses and Aboriginal Health Practitioners employed by a health service operated or managed by a Health Service Provider of the WA Department of Health.

To ensure continuity of care, record follow-up instructions in the patient's medical record.

Review all patients with gonorrhoea one to two weeks after treatment for follow-up and consideration of retesting, and to ensure that contact tracing has been completed. Consider retesting at 3 months for any reinfections. 

N. gonorrhoea may be detected up to 48 hours by culture and up to 7 days by NAAT following successful treatment.

Patients whose symptoms have not resolved within one to two weeks after treatment should be assessed for other pathologies testing; if in doubt, seek advice from a specialist sexual health physician.

Patients whose symptoms have resolved should be prioritised for re-testing if their infection was acquired overseas or if they received a non-standard treatment.

Reasonable steps should be made to review patients three months after exposure as this provides an opportunity to repeat blood tests for syphilis, HIV and HBV.

Penicillinase-producing N.gonorrhoea requires contact tracing be undertaken as a high priority to ensure that these organisms are eliminated as soon as possible from a community. Ceftriaxone-resistant N. gonorrhoea is a public health emergency and mandates immediate notification to the local PHU.

Contact tracing is important to prevent further transmission and reinfection. Always test for other STIs. If a child is diagnosed with gonorrhoea, issues of sexual abuse and/or sexual assault should be considered and mandatory notification of the infection forwarded to the local PHU.

This is a notifiable infection. Medical practitioners must complete the appropriate notification forms for all patients diagnosed with a notifiable STI/HIV, as soon as possible after confirmed diagnosis.

Epidemiology of STIs and BBVs in Western Australia

Real time gonorrhoea notification data