Gonorrhoea
Overview
- Gonorrhoea is most commonly diagnosed in men who have sex with men (MSM), among young (heterosexual) Aboriginal and Torres Strait Islander people living in remote and very remote areas and travellers returning from high prevalence areas overseas.
- Immunity to new infection is not provided by previous infection.
- Reduced susceptibility to the first line treatment is emerging in urban Australia and is being monitored closely.
Cause
Neisseria gonorrhoeae, a Gram-negative intracellular diplococci (GNID) bacterium.
Clinical presentation
| Male | Female |
| Symptoms | |
|
Dysuria |
Dyspareunia with cervicitis |
| Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function | Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function |
| Conjunctivitis: purulent, sight threatening | Conjunctivitis: purulent, sight threatening |
| Complications | |
| Epididymo-orchitis: painful, red swollen testicle/s | Pelvic inflammatory disease (PID), dyspareunia, intermenstrual bleeding, post-coital bleeding, discharge |
|
Disseminated disease: - macular rash that may include necrotic pustules - septic arthritis |
Disseminated disease: - macular rash that may include necrotic pustules - septic arthritis |
| Meningitis or endocarditis (rarely) | Meningitis or endocarditis (rarely) |
| Prostatitis (very rarely) | |
See STI Atlas for images.
Special considerations
Up to 80% of women and 10-15% of men have no genital symptoms and most people are asymptomatic or not obvious at other sites, especially the pharynx and rectum.
Diagnosis
ALWAYS test for culture before treating gonorrhoea to determine anti-microbial sensitivity and contribute to anti-microbial resistance surveillance.
| Diagnosis in males | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| NAAT |
FPU |
Always collect even if no discharge. If MSM, also collect anal and phayrngeal swab for NAAT even if asymptomatic at these sites. |
| Culture |
Urethral swab |
Only required if discharge or other local symptoms present. Gram stained urethral discharge may show gram negative intracellular diplococci but is not a sensitive test at non-urethral sites. |
| NAAT +/- culture |
Ano-rectal swab |
In asymptomatic patients, a self-collected or practitioner -collected rectal swab for NAAT is sufficient. |
|
NAAT +/- culture |
Pharyngeal swab
|
Collect if MSM. |
|
NAAT – Nucleic Acid Amplification Test |
||
| Diagnosis in females | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| NAAT +/- culture |
Endocervical swab |
If discharge/dysuria present. |
| NAAT +/- culture |
Self-collected vaginal swab |
If not examined. |
| NAAT |
FPU |
ONLY if endocervical swab/self-collected vaginal swab cannot be taken. |
|
NAAT +/- culture |
Pharyngeal swab |
If patient has had oral sex. |
| NAAT +/- culture |
Ano-rectal swab |
If patent has had anal sex or has ano-rectal symptoms. If patient declines anal examination, instruct self-collection or refer patient for testing to sexual health centre. |
| NAAT – Nucleic Acid Amplification Test FPU – First pass urine |
||
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Investigations
- NAATs are highly sensitive, allow for patient self-sampling and can be used in non-clinical and non-urban settings. They are not validated for non-genital sites however, and false positives can occur. NAATs are the most common gonorrhoea test offered by commercial laboratories in Australia.
- Gonococcal culture has high specificity and allows for antibiotic susceptibility testing but is much less sensitive than NAAT at non-genital sites. If not already collected, culture samples should be obtained at time of treatment to determine antibiotic susceptibility. Culture accuracy depends on stringent incubation and transport conditions and should reach the laboratory within 24 hours.
Special considerations
If possible, culture samples should be obtained from genital and non-genital sites to determine antibiotic susceptibility before treating someone with a positive NAAT.
Management
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Uncomplicated genital & ano-rectal infection |
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine |
Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions. |
| Uncomplicated pharyngeal infection |
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine |
Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions. |
| Adult gonococcal conjunctivitis |
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine |
Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions. |
Treatment advice
- Reduced susceptibility to the first line treatment of IMI Ceftriaxone and Azithromycin is emerging in urban Australia.
- Sharing of anti-microbial resistance genetic material between bacteria and reduced drug penetration to pharyngeal mucosa makes it the most likely site of treatment failure.
- Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to treatment.
- If a patient has an intrauterine device (IUD), leave IUD in place and treat as recommended. Seek specialist advice as needed.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered.
- Advise no sex with partners from the last 2 months until the partners have been tested and treated if necessary.
- Contact tracing
- Provide patient with fact sheet
- Notify the state/territory health department
- Consider testing for other STIs, if not undertaken at first presentation, or retesting post the window period.
Special treatment situations
Special considerations
Consider seeking specialist advice before treating any complicated presentation.
| Situation | Recommended | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Rectal coinfection |
For rectal coinfection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:
|
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Pregnant women
For more information go to the Therapeutic Goods Association's Prescribing medicines in pregnancy database and/or seek specialist advice.  |
Same as principal treatment option. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Allergy to principal treatment choice |
Seek specialist advice. |
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| Regional/remote | Amoxycillin 3g PO, stat PLUS Probenecid 1g PO, stat PLUS Azithromycin 1g PO, stat (when chlamydia not excluded). If the infection is likely to have been acquired beyond local or other remote locations, use principal treatment option. |
Contact tracing
- Contact tracing for gonorrhoea is a high priority and should be performed in all patients with confirmed infection.
- Male and female partners should be traced back for a minimum of 2 months.
- Offer recommended treatment to all sexual contacts.
See Australasian Contact Tracing Manual – Gonorrhoea for more information.
Follow up
Review in 1 week provides an opportunity to:
- Assess for symptom resolution
- Confirm contact tracing has been undertaken or offer more contact tracing support
- Provide further sexual health education and prevention counselling.
Test of Cure (TOC)
For pharyngeal, anal or cervical infection, TOC by Nucleic Acid Amplification Test (NAAT) should be performed 2 weeks after treatment is completed.
Retesting
Retest patients 3 months after exposure.
Special considerations
If TOC or retesting is positive, seek specialist advice.
Auditable outcomes
- 100% of patients diagnosed with gonorrhoea are treated with an appropriate antibiotic regimen
- 100% of patients are advised to avoid sexual contact for 7 days after treatment is administered.