There are an estimated 600,000 new gonococcal infections per year in the United States. In men, most infections cause symptoms that cause the patient to seek treatment soon enough to prevent serious sequelae. However, this may not be soon enough to prevent transmission of infection to sex partners. In contrast, many gonococcal (and also chlamydial) infections in women do not cause recognizable symptoms until the patient presents with complications, such as pelvic inflammatory disease. Symptomatic and asymptomatic pelvic inflammatory disease both result in tubal scarring, increased rates of ectopic pregnancy, and infertility.
Dual therapy is recommended for both gonococcal and chlamydial infection because patients are often coinfected with both pathogens (Krieger, 1996; Centers for Disease Control and Prevention, 1998; Centers for Disease Control and Prevention, 2006). Quinolone-resistant N. gonorrhoeae have been reported from many geographic areas, and such infections are becoming widespread in parts of Asia (Rahman et al, 2001; Tompkins and Zenilman, 2001; Trees et al, 2001).
Increasing antimicrobial resistance resulted in substantial changes in the gonorrhea treatment guidelines (Centers for Disease Control and Prevention, 2007). Fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) were the most frequently used drugs for treating gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy.
Unfortunately, this practice resulted in increasing fluoroquinolone resistance in N. gonorrhoeae. Since 2000, quinolones could no longer be recommended for treating patients who acquired their infections in Asia, the Pacific Islands, or Hawaii. Progressive increases in resistance led to extension of these recommendations to patients in California in 2002, and to treatment of gonorrhea in men who have sex with men elsewhere in the United States in 2004. Recent increases in the prevalence of fluoroquinolone-resistant N. gonorrhoeae throughout the United States led to the conclusion that fluoroquinolones can no longer be recommended for treating gonococcal infections anywhere in the United States.
Consequently, only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea (Centers for Disease Control and Prevention, 2007). Of the recommended cephalosporins, only cefixime is available in an oral formulation. However, this drug is not currently available in the United States. Spectinomycin 2 g in a single dose is considered an effective alternative regime. But this drug is also not available in the United States. This means that there is no available oral treatment recommended for gonorrhea in the United States.
Table 15-2 summarizes recommended treatment regimens for uncomplicated gonococcal infections, where the recommended treatments reliably cure =97% of infections (Centers for Disease Control and Prevention, 1998; Centers for Disease Control and Prevention, 2007). Pharyngeal infections are more difficult to treat, and few regimens reliably cure >90% of infections. Patients who cannot tolerate cephalosporins should be treated with spectinomycin (2 g as a single intramuscular dose). However, this regimen is only 52% effective for pharyngeal infections.
Routine test-of-cure cultures are no longer recommended for patients treated with the recommended regimens. Such patients should refer their sex partners for evaluation and treatment. However, patients should be reevaluated if their symptoms persistent after therapy.
Any gonococci that persist should be evaluated for antimicrobial susceptibility. Infections identified after treatment are usually reinfections rather than treatment failures. Persistent inflammation may be caused by C. trachomatis or other organisms.
A few patients have complications such as disseminated gonococcal infection, perihepatitis, meningitis, or endocarditis. These infections result from gonococcal bacteremia. Disseminated gonococcal infection often causes petechial or pustular skin lesions, asymmetrical arthralgias, tenosynovitis, or septic arthritis. Occasionally patients have perihepatitis, and rare patients have endocarditis or meningitis. N. gonorrhoeae strains that cause disseminated infection tend to cause minimal genital tract inflammation. The recommended treatment is ceftriaxone (1 g intramuscularly or intravenously every 24 hours for disseminated infection or 1 g intravenously every 12 hours for meningitis or endocarditis).