presentation of gonorrhea

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, MD, MPH, University of California San Diego

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Gonorrhea is caused by the bacterium Neisseria gonorrhoeae . It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent discharge. Dissemination to skin and joints, which is uncommon, causes sores on the skin, fever, and migratory polyarthritis or pauciarticular septic arthritis. Diagnosis is by microscopy, culture, or nucleic acid amplification tests (NAATs). Several oral or injectable antibiotics can be used, but drug resistance is an increasing problem.

(See also Overview of Sexually Transmitted Infections Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more .)

N. gonorrhoeae is a gram-negative diplococcus that occurs only in humans and is almost always transmitted by sexual contact. Urethral and cervical infections are most common, but infection in the pharynx or rectum can occur after oral or anal intercourse, and conjunctivitis may follow contamination of the eye.

Disseminated gonococcal infection (DGI) due to hematogenous spread occurs in 1% of cases, predominantly in women. DGI typically affects the skin, tendon sheaths, and joints. Pericarditis, endocarditis, meningitis, and perihepatitis occur rarely.

1. Holmes KK, Johnson DW, Trostle HJ : An estimate of the risk of men acquiring gonorrhea by sexual contact with infected females.  Am J Epidemiol 91(2):170-174, 1970. doi:10.1093/oxfordjournals.aje.a121125

Symptoms and Signs of Gonorrhea

About 10 to 20% of infected women and very few infected men are asymptomatic. About 25% of men have minimal symptoms.

Male urethritis has an incubation period from 2 to 14 days. Onset is usually marked by mild discomfort in the urethra, followed by more severe penile tenderness and pain, dysuria, and a purulent discharge. Urinary frequency and urgency may develop as the infection spreads to the posterior urethra. Examination detects a purulent, yellow-green urethral discharge, and the meatus may be inflamed.

Pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be caused by sexually... read more occurs in 10 to 20% of infected women. PID may include salpingitis, pelvic peritonitis, and pelvic abscesses and may cause lower abdominal discomfort (typically bilateral), dyspareunia, and marked tenderness on palpation of the abdomen, adnexa, or cervix.

Fitz-Hugh-Curtis syndrome is gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often mimicking biliary or hepatic disease.

Rectal gonorrhea is usually asymptomatic. It occurs predominantly in men practicing receptive anal intercourse and can occur in women who participate in anal sex. Symptoms include rectal itching, a cloudy rectal discharge, bleeding, and constipation—all of varying severity. Examination with a proctoscope may detect erythema or mucopurulent exudate on the rectal wall.

Gonococcal pharyngitis is usually asymptomatic but may cause sore throat. N. gonorrhoeae must be distinguished from N. meningitidis and other closely related organisms that are often present in the throat without causing symptoms or harm.

Gonococcal septic arthritis is a more localized form of DGI that results in a painful arthritis with effusion, usually of 1 or 2 large joints such as the knees, ankles, wrists, or elbows. Some patients present with or have a history of skin lesions of DGI. Onset is often acute, usually with fever, severe joint pain, and limitation of movement. Infected joints are swollen, and the overlying skin may be warm and red.

Diagnosis of Gonorrhea

Nucleic acid–based testing

Gram staining and culture

Gonorrhea is diagnosed when gonococci are detected via microscopic examination using a nucleic acid–based test, Gram stain, or culture of genital fluids, blood, or joint fluids (obtained by needle aspiration).

Nucleic acid amplification tests (NAATs) may be done on genital, rectal, or oral swabs and can detect both gonorrhea and chlamydial infection. NAATs further increase the sensitivity adequately to enable testing of urine samples in both sexes.

Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen. Gram stain is much less accurate for infections of the cervix, pharynx, and rectum and is not recommended for diagnosis at these sites.

Culture is sensitive and specific, but because gonococci are fragile and fastidious, samples taken using a swab need to be rapidly plated on an appropriate medium (eg, modified Thayer-Martin) and transported to the laboratory in a carbon dioxide–containing environment. Blood and joint fluid samples should be sent to the laboratory with notification that gonococcal infection is suspected. Because NAATs have replaced culture in most laboratories, finding a laboratory that can provide culture and sensitivity testing may be difficult and require consultation with a public health or infectious disease specialist.

Men with urethritis

Men with obvious urethral discharge may be treated presumptively if likelihood of follow-up is questionable or if clinic-based diagnostic tools are not available.

Samples for Gram staining can be obtained by touching a swab or slide to the end of the penis to collect discharge. Gram stain does not identify chlamydiae, so urine or swab samples for NAAT are obtained.

Women with cervicitis or pelvic inflammatory disease

A cervical swab should be sent for culture or NAAT. If a pelvic examination is not possible, NAAT of a urine sample or self-collected vaginal swab can detect gonococcal (and chlamydial) infections rapidly and reliably.

Pharyngeal or rectal exposures

Swabs of the affected area are sent for culture or NAAT.

Arthritis, disseminated gonococcal infection (DGI), or both

An affected joint should be aspirated, and fluid should be sent for culture and routine analysis (see arthrocentesis Arthrocentesis Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles (eg, myositis), peripheral... read more ). Patients with skin lesions, systemic symptoms, or both should have blood, urethral, cervical, and rectal cultures or NAAT. In about 30 to 40% of patients with DGI, blood cultures are positive during the first week of illness. With gonococcal arthritis, blood cultures are less often positive, but cultures of joint fluids are usually positive. Joint fluid is usually cloudy to purulent because of large numbers of white blood cells (typically > 20,000/microliter).

Diagnosis reference

1. Bazan JA, Peterson AS, Kirkcaldy RD, et al . Notes from the field. Increase in Neisseria meningitidis –associated urethritis among men at two sentinel clinics — Columbus, Ohio, and Oakland County, Michigan, 2015. MMWR Morb Mortal Wkly Rep 65:550–552, 2016. doi: 10.15585/mmwr.mm6521a5external icon

Screening for Gonorrhea

Asymptomatic patients considered at high risk of sexually transmitted infections (STIs) can be screened by NAAT of urine samples, thus not requiring invasive procedures to collect samples from genital sites. The following are based on CDC's Sexually Transmitted Infections (STI) Treatment Guidelines, 2021 .

Women are screened annually if they are sexually active and < 25 years of age or if they are ≥ 25 years of age, sexually active, and have one or more of the following risk factors:

Have a history of a prior STI

Engage in high-risk sexual behavior (eg, have a new sex partner or multiple sex partners; engage in sex work; or use condoms inconsistently when not in a mutually monogamous relationship)

Have a partner who has an STI or engages in high-risk behavior (eg, a sex partner who has concurrent partners)

Have a history of incarceration

Pregnant women who are < 25 years or who are ≥ 25 years with one or more of the risk factors are screened during their first prenatal visit and again during their 3rd trimester for women who are < 25 or at high risk.

There is insufficient evidence for screening heterosexual men who are at low risk for infection.

Men who have sex with men are screened at least annually if they have been sexually active within the previous year (for insertive intercourse, urine screen; for receptive intercourse, rectal swab; and for oral intercourse, pharyngeal swab), regardless of condom use. Those at increased risk (eg, with HIV infection, receive preexposure prophylaxis with antiretrovirals, have multiple sex partners, or whose partner has multiple partners) should be screened more frequently, at 3 to 6-month intervals.

Transgender and gender diverse people are screened if they are sexually active on the basis of sexual practices and anatomy (eg, annual screening for all people with a cervix who are < 25 years old; if ≥ 25 years old, people with a cervix should be screened annually if at increased risk; rectal swab based on reported sexual behaviors and exposure).

(See also the US Preventive Services Task Force’s summary of recommendations regarding screening for gonorrhea .)

Treatment of Gonorrhea

For uncomplicated infection, a single dose of ceftriaxone

Concomitant treatment for chlamydial infection

Treatment of sex partners

For disseminated gonococcal infection (DGI) with arthritis, a longer course of parenteral antibiotics

Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with the following:

A single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg)

If ceftriaxone is not available, use cefixime 800 mg orally in a single dose.

If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. In patients who have a doxycycline allergy, treat for chlamydia with a single dose of azithromycin 1 g orally.

Patients who are allergic to cephalosporins (including ceftriaxone ) are treated with

Gentamicin 240 mg IM in a single dose plus azithromycin 2 g orally in a single dose

Gonococcal purulent arthritis usually requires repeated synovial fluid drainage either with repeated arthrocentesis or arthroscopically. Initially, the joint is immobilized in a functional position. Passive range-of-motion exercises should be started as soon as patients can tolerate them. Once pain subsides, more active exercises, with stretching and muscle strengthening, should begin. Over 95% of patients treated for gonococcal arthritis recover complete joint function. Because sterile joint fluid accumulations (effusions) may develop and persist for prolonged periods, an anti-inflammatory drug may be beneficial.

Posttreatment cultures are unnecessary if symptomatic response is adequate. However, for patients with symptoms for > 7 days, specimens should be obtained, cultured, and tested for antimicrobial sensitivity.

Patients should abstain from sexual activity until treatment is completed to avoid infecting sex partners.

Sex partners

All sex partners who have had sexual contact with the patient within 60 days should be tested for gonorrhea and other STIs and treated if results are positive. Sex partners with contact within 2 weeks should be treated presumptively for gonorrhea (epidemiologic treatment).

Treatment reference

1. Centers for Disease Control and Prevention: Sexually Transmitted Infections Treatment Guidelines, 2021 : Gonococcal Infections Among Adolescents and Adults. Accessed June 27, 2022.

Neisseria gonorrhoeae infection typically causes uncomplicated infection of the urethra, cervix, rectum, pharynx, and/or conjunctivae.

Sometimes gonorrhea spreads to the adnexa, causing salpingitis, or disseminates to skin and/or joints, causing skin lesions or septic arthritis.

Diagnose using NAAT, but culture and sensitivity testing should be done when needed to detect antimicrobial resistance.

Screen high-risk patients using NAAT.

Treat uncomplicated infection with a single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg); add oral doxycycline (100 mg twice a day for 7 days) when chlamydial infection has not been excluded.

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

US Preventive Services Task Force: Chlamydia and Gonorrhea: Screening : A review of evidence that screening tests can accurately detect chlamydia and gonorrhea

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To determine whether you have gonorrhea, your healthcare professional will analyze a sample of cells. Samples can be collected with:

• A urine test. This can help identify bacteria in your urethra.
• A swab of the affected area. A swab of your throat, urethra, vagina or rectum can collect bacteria that can be identified in a lab.

Testing for other sexually transmitted infections

Your healthcare professional may recommend tests for other sexually transmitted infections. Gonorrhea increases your risk of these infections, particularly chlamydia, which often accompanies gonorrhea.

Testing for HIV also is recommended for anyone diagnosed with a sexually transmitted infection. Depending on your risk factors, tests for other sexually transmitted infections could be beneficial as well.

Gonorrhea treatment in adults

Adults with gonorrhea are treated with antibiotics. Due to emerging strains of drug-resistant Neisseria gonorrhoeae, the bacterium that causes gonorrhea, the Centers for Disease Control and Prevention recommends that uncomplicated gonorrhea be treated with the antibiotic ceftriaxone. This antibiotic is given as a shot, also called an injection.

After getting the antibiotic, you can still spread the infection to others for up to seven days. So avoid sexual activity for at least seven days.

Three months after treatment, the CDC also recommends getting tested for gonorrhea again. This is to make sure people haven't been reinfected with the bacteria, which can happen if sex partners aren't treated, or new sex partners have the bacteria.

Gonorrhea treatment for partners

Your sexual partner or partners from the last 60 days also need to be screened and treated, even if they have no symptoms. If you are treated for gonorrhea and your sexual partners aren't treated, you can become infected again through sexual contact. Make sure to wait until seven days after a partner is treated before having any sexual contact.

Gonorrhea treatment for babies

Babies who develop gonorrhea after being born to someone with the infection can be treated with antibiotics.

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Preparing for your appointment

You'll likely see your primary healthcare professional. Here's some information to help you get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.

Make a list of:

• Your symptoms, if you have any, including those that may seem unrelated to the reason for which you scheduled the appointment, and when they began.
• All medicine, vitamins or other supplements you take, including doses.
• Questions to ask your healthcare professional.

For gonorrhea, questions to ask include:

• What tests do I need?
• Should I be tested for other sexually transmitted infections?
• Should my partner be tested for gonorrhea?
• How long should I wait before resuming sexual activity?
• How can I prevent gonorrhea in the future?
• What gonorrhea complications should I be alert for?
• Are there brochures or other printed material that I can have? What websites do you recommend?
• Will I need a follow-up visit?

Don't hesitate to ask other questions.

What to expect from your doctor

Questions your healthcare professional is likely to ask you include:

• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• Have you been exposed to sexually transmitted infections?

What you can do in the meantime

Avoid sexual activity until you see your healthcare professional. Alert your sex partners that you're having symptoms so that they can arrange to see a member of their healthcare teams for testing.

• Gonorrhea: CDC fact sheet (detailed version). Centers for Disease Control and Prevention. https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea-detailed.htm. Accessed Sept. 21, 2023.
• Ghanem KG. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents. https://www.uptodate.com/contents/search. Accessed Sept. 21, 2023.
• Gonorrhea. Office on Women's Health. https://www.womenshealth.gov/a-z-topics/gonorrhea. Accessed Sept. 21, 2023.
• Gonorrhea. Merck Manual Professional Version. https://www.merckmanuals.com/professional/infectious-diseases/sexually-transmitted-diseases-stds/gonorrhea. Accessed Sept. 21, 2023.
• AskMayoExpert. Chlamydia, gonorrhea, and nongonococcal urethritis. Mayo Clinic; 2023.
• Speer ME. Gonococcal infection in the newborn. https://www.uptodate.com/contents/search. Accessed Sept. 21, 2023.
• Workowski KA, et al. Sexually transmitted infections treatment guidelines, 2021. Morbidity and Mortality Weekly Reports. 2021; doi:10.15585/mmwr.rr7004a1.

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Am Fam Physician. 2022;105(4):388-396

Related Letter to the Editor:   Doxycycline Preferred for the Treatment of Chlamydia

Patient information: See related handouts on chlamydia , written by the authors of this article, and on gonorrhea , which has been adapted from a previously published AFP article.

Author disclosure: No relevant financial relationships.

Infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae are increasing in the United States. Because most infections are asymptomatic, screening is key to preventing complications such as pelvic inflammatory disease and infertility and decreasing community and vertical neonatal transmission. All sexually active people with a cervix who are younger than 25 years and older people with a cervix who have risk factors should be screened annually for chlamydial and gonococcal infections. Sexually active men who have sex with men should be screened at least annually. Physicians should obtain a sexual history free from assumptions about sex partners or practices. Acceptable specimen types for testing include vaginal, endocervical, rectal, pharyngeal, and urethral swabs, and first-stream urine samples. Uncomplicated gonococcal infection should be treated with a single 500-mg dose of intramuscular ceftriaxone in people weighing less than 331 lb (150 kg). Preferred chlamydia treatment is a seven-day course of doxycycline, 100 mg taken by mouth twice per day. All nonpregnant people should be tested for reinfection approximately three months after treatment or at the first visit in the 12 months after treatment. Pregnant patients diagnosed with chlamydia or gonorrhea should have a test of cure four weeks after treatment.

Chlamydia trachomatis and Neisseria gonorrhoeae are the most common sexually transmitted infections (STIs) in the United States and are required to be reported to state health departments. Between 2015 and 2019, reported chlamydial infections increased by 19%, and reported gonococcal infections increased by 53%. 1 These bacteria commonly infect the urogenital, anorectal, and pharyngeal sites but can become disseminated to affect multiple organ systems. Untreated infections may lead to pelvic inflammatory disease; scarring of fallopian tubes, which can increase the risk of ectopic pregnancy; infertility; easier transmission of new HIV infection; and vertical neonatal transmission. 2

Risk Factors

Young people 15 to 24 years of age account for 61% of all newly diagnosed STIs. 1 Racial and ethnic minorities, men who have sex with men (MSM), and transgender and gender diverse people are at higher risk of STIs. Inequitable access to health insurance and physicians, language barriers, and distrust of medical systems because of discrimination account for some of these disparities, independent of individual sexual behavior. 3 , 4 Other risk factors are reviewed in Table 1 . 2

Taking a thorough sexual history is important to identify overall risk of infection, as well as anatomic site-specific risk factors. Physicians should create supportive spaces where patients feel safe sharing information by using open-ended questions; avoiding assumptions regarding sexual preferences, practices, and gender/sex; and normalizing diverse sexual experiences. To obtain a complete sexual history, the five P’s (partners, practices, pregnancy attitudes, previous STIs, and protection from STIs) model can be used as outlined in Table 2 . 2 , 5

The U.S. Preventive Services Task Force (USPSTF) recommends behavioral counseling on condom use, communication strategies for safer sex, and problem solving with those at increased risk of STIs. 6 Adolescents and adults diagnosed with an STI in the past year, people reporting irregular condom use, and those with multiple partners or with partners belonging to a high-risk group are at increased risk. Physicians should emphasize barrier protection as the best way to prevent STIs. 2

The USPSTF and Centers for Disease Control and Prevention (CDC) recommend annual screening for chlamydial and gonococcal infections to prevent infertility and pelvic inflammatory disease in sexually active people 24 years and younger with a cervix and in older people with a cervix who have risk factors. 2 , 7 The CDC also recommends at least annual screening for MSM based on their risk factors. Screening should include the pharynx, urethra, and rectum based on reported anatomic sites of exposure. After discussion with the patient, it may be necessary to screen those sites even without reported exposure because of underreporting of sexual practices. 2 Table 3 summarizes screening recommendations for chlamydial and gonococcal infections. 2 , 8 There are significant gaps in research as it pertains to screening transgender and gender diverse patients. 9 The CDC recommends screening based on an individual’s current anatomy and sexual practices. 2

Screening for urogenital infections only and neglecting pharyngeal and rectal sites of exposure will miss a substantial proportion of chlamydial and gonococcal infections. 10 In one study of women who engaged in oral or anal sex with men, the prevalence of pharyngeal gonorrhea was 3.5%; rectal gonorrhea, 4.8%; and rectal chlamydia, 11.8%. 10 Pharyngeal and rectal screening may be offered to people with female anatomy based on sexual practices and shared decision-making. 2 Current evidence for screening extra-genital sites is strongest for MSM. Urine-only screening in an STI clinic misses 83% of infections among MSM. 11 They should be screened at each anatomic site of sexual exposure, regardless of condom use, at least annually. 2 Routine testing for chlamydial infections of the oropharynx is not recommended, but many laboratories will test for gonococcal and chlamydial infections simultaneously. 2 If oropharyngeal chlamydia is diagnosed, it should be treated to decrease the risk of transmission. 2

Presentation

Most chlamydial and gonococcal infections are asymptomatic. 8 Symptoms of infection are reviewed in Table 4 . 2 Because dysuria may be a symptom of chlamydial and gonococcal infections and causes leukocytes on urinalysis, women presenting with dysuria may be inaccurately diagnosed with a urinary tract infection if STI testing is not performed. 12 , 13 In women at risk for STIs or with a negative urine culture, physicians can consider STI testing in those presenting with dysuria. A pelvic examination is not required for diagnosis and may not improve the diagnosis of chlamydia and gonorrhea beyond history and diagnostic testing. 14 However, if pelvic inflammatory disease is suspected, a pelvic examination should be performed. The differential diagnosis of chlamydial and gonococcal infections is summarized in Table 5 . 2 , 15

Diagnostic Testing

The CDC recommends using nucleic acid amplification testing (NAAT) for the diagnosis of gonococcal or chlamydial infections because it is the most sensitive. 2 Specimens can be taken from a first-stream urine sample without urethral cleansing before collection. 2 Clinician- or patient-collected vaginal or endocervical swabs are also acceptable specimens. Self-collected vaginal swabs are as sensitive as clinician-collected swabs and are preferred by patients. 16 , 17 A recent meta-analysis showed that urine samples and vaginal and endocervical swabs have similar sensitivity. 17 For patients with male genitalia, a patient- or clinician-collected urethral swab may also be obtained, although a urine specimen is preferred. 2

In 2019, the U.S. Food and Drug Administration (FDA) approved the Aptima Combo 2 Assay and Xpert CT/NG, which use NAAT, for extragenital swabs of the throat and rectum. 18 The binx health io CT/NG assay, Visby Medical Sexual Health Test NAAT, and Cepheid Xpert CT/NG (not a waived test by the Clinical Laboratory Improvement Amendments) are point-of-care tests for the diagnosis of chlamydial and gonococcal infections. 19 Point-of-care testing provides same-day results, decreases loss to follow-up, and reduces overtreatment. 20 , 21

All people who test positive or report known exposure to C. trachomatis or N. gonorrhoeae should be treated. Patients and their partners should be advised to abstain from sex for seven days after completing a single-dose regimen or until the completion of a seven-day treatment course and resolution of symptoms. 2 Nonpregnant people should be tested for reinfection approximately three months after treatment or at the first visit in the 12 months after treatment. Follow-up care recommendations are reviewed in Table 6 . 2 , 22 , 23

Patients presenting clinically with nongonococcal urethritis can be treated empirically at the time of evaluation while diagnostic testing is pending. Cervicitis should be treated presumptively in those younger than 25 years or those at high risk of infection if NAAT is not available or follow-up is uncertain.

CHLAMYDIAL TREATMENT

Although spontaneous clearance of chlamydial infections is possible, people with positive test results should always be treated. 24 Because of increasing macrolide resistance, the recommended treatment for non-pregnant people is now doxycycline, 100 mg, twice per day for seven days. 2 Physicians may alternatively choose to treat patients with a single 1-g dose of azithromycin, especially when adherence to a multidose regimen may be a concern. 2 Treatment regimens are reviewed in Table 7 . 2 , 22 , 23

GONOCOCCAL TREATMENT

In 2018, more than one-half of cases of gonococcal infection were estimated to be resistant to at least one drug, leading the CDC to change treatment recommendations to higher doses of ceftriaxone 25 ( Table 8 2 , 15 , 25 ) . Azithromycin is no longer a recommended therapy for nonpregnant individuals because of an observed sevenfold increase in gonococcal resistance between 2013 and 2018. 25

UNRESOLVED SYMPTOMS

Most treatment failures are caused by reinfection from sex partners who have not received adequate treatment, rather than treatment failure from antimicrobial resistance. 2 If symptoms do not resolve or a test is persistently positive in a situation in which reinfection seems unlikely (i.e., the patient has reported no new sexual contact and is taking medication as prescribed), an infectious disease specialist and local health department should be consulted in case of possible antimicrobial resistance. 2

PARTNER EVALUATION AND EXPEDITED PARTNER THERAPY

If seeking care in person is not possible, expedited partner therapy is a strategy in which sex partners of a person diagnosed with a chlamydial or gonococcal infection within the past 60 days can be prescribed treatment without being seen by the physician. This strategy is supported by the American Academy of Family Physicians. 2 , 26 If the diagnosed person has not had a sex partner in the past 60 days, the most recent sex partner can be offered treatment. Sex partners with symptoms should be referred for evaluation and treatment. 2 Laws in 46 states permit expedited partner therapy. 27 Because recommended gonococcal treatment is based on intramuscular administration of medication, every effort should be made to see partners of infected patients in person for treatment and testing for other STIs. 28 If permissible by state law and the partner is highly unlikely to receive care, partners of those with gonococcal infections may be treated with a single dose of cefixime (Suprax), 800 mg orally, with the addition of 100 mg of oral doxycycline twice per day for seven days if chlamydial infection was not excluded. 28 Written instructions should be given to patients to convey to their partners how to take the medication, warnings about side effects and allergies, when to seek medical care, and STI education. 2 The best evidence for use of expedited partner therapy services is for male partners of women with gonococcal or chlamydial infections. 27 The risk of missing concomitant infections in MSM requires a more nuanced discussion, but these patients may be offered expedited partner therapy through shared decision-making. 28

LYMPHOGRANULOMA VENEREUM

Lymphogranuloma venereum is caused by a C. trachomatis serovar and can become invasive and cause colorectal fistulas and strictures. Treatment should be started presumptively at the initial visit to prevent complications if there is clinical suspicion for lymphogranuloma venereum. 2 Partners should be evaluated and treated empirically with a non–lymphogranuloma venereum chlamydial infection regimen. 2

Gonococcal and chlamydial infections in pregnancy are associated with increased risks, including preterm birth, premature rupture of membranes, stillbirth, low-birth-weight infants, and neonatal infection. 29 , 30 Pregnant patients should be screened as outlined in Table 3 . 2 , 8 Those at high risk of infection should be screened again in the third trimester. 2 Anyone diagnosed with a gonococcal or chlamydial infection during pregnancy should have a test of cure approximately four weeks after treatment, at three months after diagnosis, and in their third trimester. 2

NEONATAL INFECTIONS

The prevalence of perinatal gonococcal infections is 0.2 to 0.4 cases per 100,000 live births. 31 The USPSTF recommends universal prophylaxis with ocular erythromycin 0.5% ointment to prevent gonococcal ophthalmia neonatorum. The risk of infection without prophylaxis is 30% to 40%, and it can cause blindness as early as 24 hours after birth. 31 N. gonorrhoeae can also cause septic arthritis, meningitis, rhinitis, vaginitis, urethritis, pneumonia, and skin infections in neonates. 2 Asymptomatic newborns exposed to gonorrhea at birth from an untreated birthing parent should be swabbed for infection at the conjunctiva, oropharynx, vagina, and rectum and presumptively treated for gonorrhea. 2

Neonates are at high risk of contracting an infection if chlamydia is untreated in pregnancy. 2 , 32 Infants exposed during birth do not need to receive chlamydial-specific prophylactic antibiotics but should be monitored clinically for symptoms. 2 Ophthalmia neonatorum presents a few days to several weeks after birth with eyelid edema, discharge, and ocular congestion. 2 , 32 Chlamydial infections of the eye are not prevented by prophylactic erythromycin ointment. 32 Unlike trachoma, which is a chronic infection spread through close contact, clothes, and flies, ophthalmia neonatorum does not result in scarring and blindness. Diagnosis of ophthalmia neonatorum can be made by swabbing the conjunctiva for culture, direct fluorescence antibody testing, or NAAT. 2 The recommended treatment is oral erythromycin. 2 There should be close follow-up because a second course may be required. 2 C. trachomatis can also cause neonatal pneumonia. Infants present between two and 19 weeks of age with a staccato cough, tachypnea, rhinorrhea, and rales. 2 , 32 Exposed infants are at high risk; if they present with pneumonia, they should be treated empirically for chlamydial infection while awaiting test results from culture, direct fluorescence antibody testing (lower sensitivity), or NAAT (not FDA approved for the nasopharynx). 2 , 32

Any child diagnosed with gonococcal or chlamydial infections should be evaluated for sexual abuse. 2 , 32 Although perinatally transmitted chlamydial infections can be found in children up to three years of age, sexual abuse is the most common cause of infection in children. 2

MANAGEMENT DURING THE COVID-19 PANDEMIC

Disparities in STI testing have been more pronounced due to reallocation of resources for SARS-CoV-2 testing and decreased testing due to social distancing and stay-at-home orders. 3 , 19 However, telemedicine use has increased during the COVID-19 pandemic and is well-suited for STI screening because physical examination is not essential for diagnosis or treatment. 14 , 33 At-home C. trachomatis and N. gonorrhoeae self-testing kits are not FDA approved; however, multiple studies have found that when patients are instructed by a physician via telemedicine, self-collected swabs at home will diagnose cases similarly to office-collected samples, with increased volume of testing offsetting a slightly lower test sensitivity. 19 , 34 – 36 Physicians can safely incorporate home-based testing and treatment into telehealth practice.

This article updates previous articles on this topic by Mishori, et al. 23 ; Mayor, et al. 15 ; Miller 37 ; and Miller . 38

Data Sources: The U.S. Preventive Services Task Force, Cochrane Database of Systematic Reviews, Essential Evidence Plus, Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, and American Academy of Family Physicians websites were reviewed for relevant publications. A PubMed search was conducted using the terms Neisseria gonorrhoeae , Chlamydia trachomatis , diagnosis, and treatment for the past 10 years including English language, meta-analysis, randomized controlled trials, reviews, and systematic reviews. Search dates: January 28, 2021; February 14, 2021; March 30, 2021; July 25, 2021; and November 27, 2021.

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2019. U.S. Department of Health and Human Services; 2021. Accessed November 28, 2021. https://www.cdc.gov/std/statistics/2019/default.htm

• Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.

Lieberman JA, Cannon CA, Bourassa LA. Laboratory perspective on racial disparities in sexually transmitted infections. J Appl Lab Med. 2021;6(1):264-273.

Hamilton DT, Morris M. The racial disparities in STI in the U.S.: concurrency, STI prevalence, and heterogeneity in partner selection. Epidemics. 2015;11:56-61.

Savoy M, O’Gurek D, Brown-James A. Sexual health history: techniques and tips. Am Fam Physician. 2020;101(5):286-293. Accessed November 28, 2021. https://www.aafp.org/afp/2020/0301/p286.html

• Krist AH, Davidson KW, Mangione CM, et al. Behavioral counseling interventions to prevent sexually transmitted infections: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(7):674-681.
• Cantor A, Dana T, Griffin JC, et al. Screening for chlamydial and gonococcal infections: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;326(10):957-966.

Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: the case for screening. Prev Med. 2003;36(4):502-509.

• Van Gerwen OT, Jani A, Long DM, et al. Prevalence of sexually transmitted infections and human immunodeficiency virus in transgender persons: a systematic review. Transgend Health. 2020;5(2):90-103.
• Bamberger DM, Graham G, Dennis L, et al. Extragenital gonorrhea and chlamydia among men and women according to type of sexual exposure. Sex Transm Dis. 2019;46(5):329-334.
• Marcus JL, Bernstein KT, Kohn RP, et al. Infections missed by urethral-only screening for chlamydia or gonorrhea detection among men who have sex with men. Sex Transm Dis. 2011;38(10):922-924.
• Tomas ME, Getman D, Donskey CJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol. 2015;53(8):2686-2692.
• Shipman SB, Risinger CR, Evans CM, et al. High prevalence of sterile pyuria in the setting of sexually transmitted infection in women presenting to an emergency department. West J Emerg Med. 2018;19(2):282-286.
• Farrukh S, Sivitz AB, Onogul B, et al. The additive value of pelvic examinations to history in predicting sexually transmitted infections for young female patients with suspected cervicitis or pelvic inflammatory disease. Ann Emerg Med. 2018;72(6):703-712.e1.

Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections [published correction appears in Am Fam Physician . 2013;87(3):163]. Am Fam Physician. 2012;86(10):931-938. Accessed September 22, 2021. https://www.aafp.org/afp/2012/1115/p931.html

• Lunny C, Taylor D, Hoang L, et al. Self-collected versus clinician-collected sampling for chlamydia and gonorrhea screening: a systemic review and meta-analysis. PLoS One. 2015;10(7):e0132776.
• Rönn MM, Mc Grath-Lone L, Davies B, et al. Evaluation of the performance of nucleic acid amplification tests (NAATs) in detection of chlamydia and gonorrhoea infection in vaginal specimens relative to patient infection status: a systematic review. BMJ Open. 2019;9(1):e022510.

U.S. Food and Drug Administration. FDA news release: FDA clears first diagnostic tests for extragenital testing for chlamydia and gonorrhea. May 23, 2019. Accessed March 10, 2021. https://www.fda.gov/news-events/press-announcements/fda-clears-first-diagnostic-tests-extragenital-testing-chlamydia-and-gonorrhea

• Kersh EN, Shukla M, Raphael BH, et al. At-home specimen self-collection and self-testing for sexually transmitted infection screening demand accelerated by the COVID-19 pandemic: a review of laboratory implementation issues. J Clin Microbiol. 2021;59(11):e0264620.
• Van Der Pol B, Taylor SN, Mena L, et al. Evaluation of the performance of a point-of-care test for chlamydia and gonorrhea. JAMA Netw Open. 2020;3(5):e204819.
• Gaydos CA, Ako MC, Lewis M, et al. Use of a rapid diagnostic for Chlamydia trachomatis and Neisseria gonorrhoeae for women in the emergency department can improve clinical management: report of a randomized clinical trial. Ann Emerg Med. 2019;74(1):36-44.
• Dombrowski JC, Wierzbicki MR, Newman LM, et al. Doxycycline versus azithromycin for the treatment of rectal chlamydia in men who have sex with men: a randomized controlled trial. Clin Infect Dis. 2021;73(5):824-831.

Mishori R, McClaskey EL, WinklerPrins VJ. Chlamydia trachomatis infections: screening, diagnosis, and management. Am Fam Physician. 2012;86(12):1127-1132. Accessed September 22, 2021. https://www.aafp.org/afp/2012/1215/p1127.html

• Geisler WM, Lensing SY, Press CG, et al. Spontaneous resolution of genital Chlamydia trachomatis infection in women and protection from reinfection. J Infect Dis. 2013;207(12):1850-1856.
• St Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916.

American Academy of Family Physicians. Expedited partner therapy. Accessed August 1, 2021. https://www.aafp.org/about/policies/all/expedited-partner-therapy.html

Centers for Disease Control and Prevention. Expedited partner therapy. U.S. Department of Health and Human Services; 2021. Accessed November 27, 2021. https://www.cdc.gov/std/ept/default.htm

Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. U.S. Department of Health and Human Services; 2021. Accessed November 27, 2021. https://www.cdc.gov/std/ept/gc-guidance.htm

• He W, Jin Y, Zhu H, et al. Effect of Chlamydia trachomatis on adverse pregnancy outcomes: a meta-analysis. Arch Gynecol Obstet. 2020;302(3):553-567.
• Vallely LM, Egli-Gany D, Wand H, et al. Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis. Sex Transm Infect. 2021;97(2):104-111.
• Curry SJ, Krist AH, Owens DK, et al. Ocular prophylaxis for gonococcal ophthalmia neonatorum: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;321(4):394-398.

Baker CJ. Red Book: Atlas of Pediatric Infectious Diseases . 4th ed. American Academy of Pediatrics; 2020.

• Car J, Koh GCH, Foong PS, et al. Video consultations in primary and specialist care during the COVID-19 pandemic and beyond. BMJ. 2020;371:m3945.
• Fajardo-Bernal L, Aponte-Gonzalez J, Vigil P, et al. Home-based versus clinic-based specimen collection in the management of Chlamydia trachomatis and Neisseria gonorrhoeae infections. Cochrane Database Syst Rev. 2015;(9):CD011317.
• Carnevale C, Richards P, Cohall R, et al. At-home testing for sexually transmitted infections during the COVID-19 pandemic. Sex Transm Dis. 2021;48(1):e11-e14.
• Chow EPF, Bradshaw CS, Williamson DA, et al. Changing from clinician-collected to self-collected throat swabs for oropharyngeal gonorrhea and chlamydia screening among men who have sex with men. J Clin Microbiol. 2020;58(9):e01215-20.

Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Physician. 2006;73(10):1779-1784. Accessed September 22, 2021. https://www.aafp.org/afp/2006/0515/p1779.html

Miller KE. Diagnosis and treatment of Chlamydia trachomatis infection [published correction appears in Am Fam Physician . 2008;77(7) 920]. Am Fam Physician. 2006;73(8):1411-1416. Accessed September 22, 2021. https://www.aafp.org/afp/2006/0415/p1411.html

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Original Author(s): Grace Fitzgerald Last updated: 11th June 2019 Revisions: 6

• 1 Pathophysiology
• 2 Risk Factors
• 3.1 Genital infection
• 3.2 Rectal infection
• 3.3 Pharyngeal infection
• 4 Differential Diagnoses
• 5 Investigations
• 6 Management
• 7 Complications
• 8 Gonorrhoea in Pregnancy

Gonorrhoea is a curable sexually transmitted infection caused by the Gram-negative bacterium Neisseria gonorrhoeae . In the UK, gonorrhoea is the second most common bacterial STI (after chlamydia) and predominantly affects people under the age of 25 and men who have sex with men.

Throughout this article we will discuss the pathophysiology of gonorrhoea, its clinical features, management and how it may affect pregnancy and the neonate.

Pathophysiology

Gonorrhoea is transmitted through unprotected vaginal/oral/anal sex and can also be vertically transmitted from mother to child.

Neisseria gonorrhoeae is a Gram-negative diplococcus that has a strong affinity for mucous membranes. The organism can infect the uterus, urethra, cervix, fallopian tubes, ovaries, testicles, rectum, throat and less commonly the eyes. Once adhered to the mucous membrane, it invades the host cell and causes acute inflammation. N. gonorrhoea also has surface proteins that bind to the receptors of immune cells thus preventing an immune response.

Risk Factors

The following are risk factors associated with gonorrhoea, most of which are common to other STIs:

• Aged <25 years
• Men who have sex with men
• Living in high density urban areas
• Previous gonorrhoea infection
• Multiple sexual partners

Clinical Features

While gonorrhoea is often asymptomatic, as occurs in around 50% of female cases, symptoms can usually develop 2-5 days following infection:

Genital infection

Figure 1. Vaginal discharge in female gonorrhoea infection

• Altered/increased vaginal discharge (commonly thin, watery, green or yellow)
• Dyspareunia
• Lower abdominal pain
• Rarely – intermenstrual and/or post-coital bleeding
• Mucopurulent endocervical discharge
• Easily induced cervical bleeding
• Pelvic tenderness

Often examination can be normal.

• Mucopurulent/purulent urethral discharge
• Epididymal tenderness

Rectal infection

• Usually asymptomatic
• Anal discharge
• Anal pain/discomfort

Pharyngeal infection

• Usually asymptomatic (>90%)

Differential Diagnoses

A full STI screen should be undertaken for a patient presenting with gonorrhoea due to the common presenting symptoms of various STIs.

In particular, it is often very difficult to clinically differentiate between gonorrhoea and chlamydia infection. These infections often co-exist and therefore empirical treatment for gonorrhoea has the aim of covering both the causative organisms.

Investigations

If someone has suspected gonorrhoea, they should be referred to a GUM clinic or other specialist sexual health service for specimens to be taken:

• Endocervical/vaginal swab – NAAT
• Endocervical/urethral swab – microscopy and culture
• First pass urine – NAAT
• Urethral/meatal swab – microscopy and culture
• Swabs for NAAT + microscopy & culture can be obtained from the throat, rectum or eye if indicated.

These swabs should then be sent for microscopy , culture or nucleic acid amplification testing (NAAT) . NAATs are the standard investigation for chlamydia and these tests often provide dual testing for both chlamydia and gonorrhea.

While waiting for these laboratory results the patient should be treated with empirical antibiotics if their signs and symptoms are indicative of gonorrhoea.

Following diagnosis of gonorrhoea, a patient should be treated with a single dose of intramuscular ceftriaxone 1g.

Patients should be offered screening for other STIs, especially chlamydia, as co-infections are common. People should be encouraged to contact previous sexual partners to advise them to be screened and treated empirically for gonorrhoea.

Future safe sex should also be encouraged and patients should abstain from sex until both partners have completed treatment. To ensure antibiotics have successfully treated a patient, a test of cure is recommended during a follow up appointment.

For full details please refer to the BASHH UK guidelines for the management of gonorrhoea .

Complications

If gonorrhoea is left untreated in females, it can lead to pelvic inflammatory disease (PID) , which can result in chronic pain, infertility and ectopic pregnancy. In males, gonorrhoea can spread from the urethra to the testes causing epididymo-orchitis which is painful but rarely leads to infertility. It can also lead to prostatitis . Disseminated gonococcal infection (DGI) is uncommon but can lead to joint pain and skin lesions.

A patient should be admitted to hospital if:

• Systemic symptoms are identified (e.g. malaise, joint pain, fever, rash) as this suggests disseminated gonorrhoea which can potentially develop into a life threatening infection such as gonococcal meningitis.
• Females show signs of complicated or severe pelvic inflammatory disease.

Gonorrhoea in Pregnancy

Having gonorrhoea during pregnancy may be associated with complications such as perinatal mortality, spontaneous abortion, premature labour and early fetal membrane rupture.

Figure 2. Neonatal conjunctivitis may develop if born to an untreated woman with gonorrhoea.

Gonorrhoea can be vertically transmitted during delivery from an untreated mother and this can cause the neonate to have gonococcal conjunctivitis, where the neonate will experience eye pain, redness and discharge. Prophylactic antibiotics can prevent this and treatment during pregnancy is the same as for uncomplicated gonorrhoea. For the infected neonate, urgent referal and appropriate treatment is necessary to prevent long term damage and blindness.

• Rarely - intermenstrual and/or post-coital bleeding

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Gonorrhea infection

Highlights & basics, diagnostic approach, risk factors, history & exam, differential diagnosis.

• Tx Approach

Emerging Tx

Complications.

PATIENT RESOURCES

Patient Instructions

Gonorrhea infection is a common STI caused by Neisseria gonorrhoeae , a gram-negative diplococcus bacterium that is closely related to other human Neisseria species.

Men typically present with a urethral discharge; women are often asymptomatic, but may have vaginal discharge.

Risk factors include multiple sex partners in recent months, known partner with gonorrhea, drug use, prior STI, and men who have sex with men.

If left untreated, N gonorrhoeae can disseminate to areas of the body to cause skin and synovial infections; rarer complications include meningitis, endocarditis, and perihepatic abscesses.

High rates of antimicrobial resistance have been reported, and antibiotic treatment should be guided by local and national guidelines. The main treatment for uncomplicated gonorrhea is monotherapy with single-dose intramuscular ceftriaxone.

The treatment of N gonorrhoeae is important in the prevention of infertility, chronic pelvic pain, and ectopic pregnancy in women.

If acquired congenitally from an infected mother, the neonate can present with ophthalmia neonatorum, which left untreated can cause blindness.

Quick Reference

Key Factors

urethral discharge in men

Tenderness and/or swelling of the epididymis, mucopurulent or purulent exudate at the endocervix.

Other Factors

pelvic pain in women

Urethral irritation in men, dysuria in men, tenderness and/or swelling of testis, tenderness and/or swelling of prostate, anal pruritus, mucopurulent discharge from the rectum, rectal pain, rectal bleeding, vaginal discharge, cervical friability, uterine, adnexal, or cervical motion tenderness, uterine mass, anterior cervical lymphadenopathy, conjunctivitis, skin lesions (papules, bullae, petechiae, or necrotic) at extremities, polyarthritis, purpuric rash, positive brudzinski and kernig sign, focal cerebral signs, ophthalmia neonatorum, urethritis (infantile).

Diagnostics Tests

1st Tests to Order

nucleic acid amplification test (NAAT)

Urinalysis in men, gram stain of urine sediment, gram stain of urethral discharge, syphilis test.

Other Tests to consider

transvaginal ultrasound

Pelvic ct/mri, treatment options, nonpregnant >45 kg: urogenital/anorectal or pharyngeal infection (excluding complicated genitourinary infection).

with history of sexual assault

nonpregnant >45 kg: complicated genitourinary infection

with mild to moderate pelvic inflammatory disease (PID)

with severe pelvic inflammatory disease (PID)

with epididymitis (suspected sexually transmitted)

with conjunctivitis

Common Vignette 1

Common Vignette 2

Other Presentations

Epidemiology

Pathophysiology.

• Sheldon Morris, MD, MPH
• Vani Dandolu, MD, MPH
• Eva Jungmann, FRCP MSc

This gram-stained micrograph of a rectal smear specimen reveals the presence of diplococcal Neisseria gonorrhoeae bacteria

This patient presented with symptoms later diagnosed as due to gonococcal pharyngitis

Gonococcal conjunctivitis of the right eye

Gonococcal arthritic patient with inflammation of the skin of her right arm due to a disseminated Neisseria gonorrhoeae bacterial infection

Cutaneous lesions on the left ankle and calf due to a disseminated Neisseria gonorrhoeae infection

Gonococcal arthritis of the hand, which caused the hand and wrist to swell

A newborn with gonococcal ophthalmia neonatorum caused by a maternally transmitted gonococcal infection

Photomicrograph revealing the histopathology in an acute case of gonococcal urethritis using gram-stain technique

Partners (sex of partners, number of partners in prior 2 months/1 year)

Prevention of pregnancy - trying to conceive or contraceptive use

Protection from STIs/HIV - what does the patient do to protect him/herself from STIs and HIV?

Practices or types of sexual activities (oral/vaginal/anal and insertive/receptive), condom use

Past STIs/HIV - any prior diagnoses of STIs or HIV or viral hepatitis.

Physical exam

Inspection and palpation of the testis, epididymis, and spermatic cord should be performed. The penis shaft, glans, and meatus should also be examined and the presence of discharge assessed. A prostate exam is required if symptoms of prostatitis are present.

A swollen and/or tender testicle (usually one-sided) on palpation may indicate orchitis.

A swollen and/or tender epididymis on palpation may indicate epididymitis, which occurs in <5% of men with gonorrhea. [ 40 ] Unilateral testicular pain (without discharge or dysuria) and fever are also symptoms of epididymitis. [ 2 ]

The external genitalia (labia and clitoris) should be inspected before speculum exam of the cervix and vagina. It is recommended that lubricant jelly not be used as it can destroy Neisseria gonorrhoeae . Presence of mucopurulent or purulent exudate at the endocervix is looked for.

PID is the most important complication of gonorrhea in women. It may develop in up to one third of women with gonorrhea, and can lead to long-term sequelae even after resolution of infection. [ 41 ] [ 42 ] The most common sequelae of PID are chronic pelvic pain (40%), tubal infertility (10.8%), and ectopic pregnancy (9.1%). [ 43 ] [ 44 ] A bimanual exam for cervical motion tenderness, uterine tenderness, and adnexal tenderness is particularly important to assess possible ascending infection resulting in PID. Cervical motion tenderness is assessed using 1 or 2 fingertips to move the cervix and asking the patient if any pain results. Presence of a cervical mass suggests PID.

Bleeding that occurs with gentle passage of a cotton swab through the cervical os suggests cervical friability and cervicitis. [ 23 ] ​

Rectal gonorrhea may cause mucopurulent discharge from the anus.

The pharynx is examined for erythema and exudate. Image Anterior cervical lymphadenopathy may also be present. [ 2 ]

Gonococcal conjunctivitis can present with a thick white/yellow discharge. Examination of the eyes with a slit lamp is recommended so that infection of the cornea can be excluded.

Suspected disseminated gonococcal infection (DGI)

Pediatric gonococcal infection.

The most severe manifestations of pediatric gonococcal infection are ophthalmia neonatorum and sepsis, which can include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and reinfection at site of fetal monitoring: for example, through scalp electrodes. Image

Infants at increased risk for gonococcal ophthalmia neonatorum are those who do not receive ophthalmia prophylaxis and those whose mothers have had no prenatal care, or have a history of STIs or substance misuse. [ 23 ] ​ In the US, routine prophylactic eye drops are recommended for all newborns. [ 38 ] [ 46 ]

Sexual abuse is the most frequent cause of STIs (including gonococcal infection) in preadolescent children. [ 14 ] Anorectal and pharyngeal infection are common and frequently asymptomatic in sexually abused children. Vaginitis is the most common manifestation in preadolescent girls.

Laboratory evaluation: overview

Laboratory evaluation: men with urethral discharge, laboratory evaluation: men without urethral discharge, laboratory evaluation: women, laboratory evaluation: nongenital sites, laboratory evaluation: patients with suspected dgi, laboratory evaluation: infants with suspected gonococcal infection, laboratory evaluation for suspected gonococcal infection: children, adolescents, and adults with possible sexual assault, further investigations, age 20 to 24 years.

One of the strongest predictors of gonorrhea, with rates 4 to 5 times higher than the national average. According to US data, the highest rates in men and women are seen in the 20 to 24 years age group. [ 3 ] ​

men who have sex with men (MSM)

In the US, about one third of gonorrhea cases are reported in MSM. [ 3 ] ​

In 2016, the Centers for Disease Control and Prevention's MSM Prevalence Monitoring Project in several urban STI clinics in the US showed high median site-specific positivity for rectal gonorrhea (15.9%) and pharyngeal gonorrhea (8.8%) among MSM. [ 24 ]

black ancestry

In the US, people of black ancestry have a rate that remains higher than other races/ethnicities and is between 8 and 9 times higher than the rate in white people (652.9 vs. 78.9 cases per 100,000). [ 3 ] ​ There is no biologic basis for this; rate differences by race/ethnicity may represent contextual factors such as geography, socioeconomic status, and social structure that affect sexual networks. [ 25 ] In the US-based National Longitudinal Study of Adolescent Health (Add Health) study the highest rate among those ages 18 to 26 years was seen in black people (2.13%). [ 26 ] ​

current or prior history of STI

This is consistently found to be a risk factor for repeat infections and therefore is a clear indication for screening. [ 27 ] [ 28 ] [ 29 ] In the Add Health study (a US-based cohort study of adults ages 18 to 26 years), chlamydia was found as a coinfection in 69% of those with gonorrhea. [ 26 ] ​ In this study most gonorrhea was asymptomatic, which may be because symptomatic people had received treatment. Women with prior bacterial vaginitis had a 26% increased risk of having gonorrhea. Bacterial vaginosis is associated with an increased risk of subsequent gonorrhea infection. [ 30 ]

multiple recent sex partners

The definition of multiple sex partners is variable, but 2 or more partners in the most recent 2 months is a commonly accepted definition. [ 29 ] [ 31 ] [ 32 ] Working in the commercial sex industry qualifies as exposure to multiple partners.

inconsistent condom use

Sexual contact without a condom is a primary risk factor for gonorrhea infection. This includes any penetrative sex (usually referring to a penis) that involves a mucosa-lined orifice (oropharynx, vagina, and anus). [ 5 ] [ 6 ] [ 7 ] [ 8 ]

risk factors of partner

Unprotected sex is required for gonorrhea infection, but it does not constitute a high risk on its own if it is within a monogamous relationship. However, it is important to also consider the partner's risk factors because even if the patient has one partner, that partner may be linked to a high-risk sexual network by any of the same factors listed.

history of sexual or physical abuse

Reinfection of women with gonorrhea or chlamydia is associated with a history of physical or sexual abuse. [ 33 ]

substance use

Often linked to high-risk sexual networks and therefore in many circumstances can be reasonably considered a risk factor. [ 5 ] [ 6 ] [ 7 ] [ 8 ]

past incarceration

Some studies have demonstrated that people with a history of imprisonment may have higher rates of STIs (including gonorrhea) than those with no history of imprisonment. [ 23 ] ​ In the US, 4.4% of females and 1.2% of males entering a juvenile correctional institution in 2011 were positive for gonorrhea. [ 34 ]

high-morbidity community

It is always important to consider the local epidemiologic factors in a decision to screen a person. Within the context of a local outbreak of gonorrhea the threshold to initiate screening may be different.

Early symptom of gonorrhea.

Suggests epididymitis. This requires specialized treatment and needs to be distinguished from testicular torsion.

Mucopurulent cervicitis is the classical sign of gonorrhea infection in women but as a sign it is not common enough nor specific enough for the predictive value to be sufficient to make a diagnosis without supportive laboratory tests.

Physical findings include frank mucopus on swab and cervical os friability.

Considered for an STI and needs a bimanual exam. A significant number of women may have endometritis without overt symptoms. [ 41 ] If no overt pelvic pain is reported it also important to elicit whether pain occurs with sex.

Early symptom of gonorrhea usually followed by discharge hours to days later. [ 18 ]

The most common symptom of gonorrhea in men and will precede discharge.

Orchitis is usually one-sided.

Prostatitis is an uncommon finding with gonorrhea but is suspected if urinary obstructive symptoms or pelvic pain is present.

Associated with rectal gonorrhea infection.

Associated with rectal gonorrhea infection. Usually occurs with a bowel movement.

Associated with rectal gonorrhea infection. More common in men who have sex with men.

Women with gonorrhea may have some vaginal discharge, but lack of a discharge does not exclude infection.

In most vaginal discharges, other types of vaginitis such as trichomonas, yeast, and bacterial vaginosis predominate.

The discharge should be sent for microscopy. Leukorrhea is defined as >10 white blood cell count on high-power field of a vaginal fluid smear. [ 23 ] ​

Bleeding that occurs with gentle passage of a cotton swab through the cervical os suggest cervicitis. [ 23 ] ​

Tenderness suggests pelvic inflammatory disease, which requires specialized treatment.

The presence of a mass suggests pelvic inflammatory disease, which requires specialized treatment.

May be present in pharyngeal gonorrhea infection.

Gonococcal conjunctivitis presents with thick/white yellow discharge. Image

Can be seen with ascending gonorrhea infection or disseminated gonorrhea infection.

Indication of disseminated gonococcal infection. Image

Indication of disseminated gonococcal infection. Most commonly affected joints are wrists, ankles, and small joints of hands and feet. Image

Manifestation of gonococcal meningitis.

Manifestation of gonococcal endocarditis

Neonatal conjunctivitis. One of the most severe manifestations of pediatric gonococcal infection. Image

Less severe manifestation of pediatric gonococcal infection.

Most common manifestation of gonococcal infection in preadolescent girls. May occur in infants with gonococcal infection.

positive for gonorrhea

Nonculture testing using NAATs is generally considered the most robust method for testing, but clinicians should use the approved local diagnostic method. [ 23 ] ​​ [ 48 ] ​ The Association of Public Health Laboratories and the Centers for Disease Control and Prevention recommend NAATs for the detection of genital tract infections with gonorrhea without routine repeat testing for positive results. [ 47 ] [ 50 ]

Useful for urine, urethral, cervical, and vaginal specimens. However, it is not Food and Drug Administration-approved for use in nongenital sites (pharyngeal and rectum). Individual laboratories can perform NAATs at nongenital sites if they satisfy regulations for Clinical Laboratory Improvement Amendments compliance before reporting results. [ 47 ] [ 50 ]

Most sensitive method to detect gonorrhea but has less than 100% specificity, particularly with pharyngeal and rectum specimens.

Samples for NAATs can be collected by the clinician/healthcare provider or the patient (self-collected). [ 23 ] ​​ [ 49 ] Self-collected specimens sent for NAATs have been found to be noninferior to clinician-collected specimens, although local laboratory validation of this collection method should be conducted. [ 51 ] [ 52 ]

A NAAT for chlamydial infection is also recommended. [ 23 ] ​

positive chocolate agar culture

Urethral, endocervical, rectal, pharyngeal, blood, synovial fluid, cerebrospinal fluid, or conjunctival specimen can be used.

Definitive diagnostic test but has deficiencies in sensitivity with pharyngeal and rectal sites: sensitivity of culture for the pharynx is about 50%. [ 60 ]

It is the only available method to test for antimicrobial sensitivities.

Culture had been the only Food and Drug Administration-approved method for testing rectum and pharyngeal specimens, and it may be the only available option in some regions, but some NAAT platforms are now approved for these nongenital sites. [ 23 ] ​

Culture of swabs for chlamydial infection may also be requested.

positive leukocyte esterase

Useful if the patient has no urethral discharge.

Provides a presumptive diagnosis of urethritis and guides differential and further investigation. [ 23 ] ​

≥10 WBC per high-power field or ≥2 WBC per oil immersion field; intracellular gram-negative diplococci in polymorphonuclear leukocytes

Confirms urethritis and guides differential and further investigation.

Strongly suggests gonorrhea if organism seen. But does not rule out gonorrhea if organisms not seen. [ 61 ]

intracellular gram-negative diplococci in polymorphonuclear leukocytes

Confirms urethritis and guides differential and further investigation. Image

may be positive

Routine to rule out HIV. Time to HIV seropositivity with a third-generation enzyme immunoassay can be >21 days.

Routine to rule out syphilis. A Venereal Disease Research Laboratory test or serum rapid plasma reagin (RPR) test can take up to 3 months to become positive. Some laboratories may perform a reverse sequence screening algorithm that uses a serologic test before the RPR.

thickening of endometrium or tubes; fluid in the tubes or abscess

Highly specific for pelvic inflammatory disease. Useful in presence of chronic ascending infection resulting in tubo-ovarian abscess.

inflammatory changes of fallopian tubes and ovaries; abnormal fluid collection; thickened ligaments

Highly specific for pelvic inflammatory disease (PID). When diagnosis of PID is uncertain or ultrasound is equivocal, either a CT or MRI may be performed, if available.

Chlamydia infection

Differentiating Signs/Symptoms

There are no history or physical exam features that can distinguish between chlamydia and gonorrhea infection except for disseminated infection, which is unique to gonorrhea.

Chlamydia is around 10 times more common than gonorrhea in young populations. [ 26 ] ​ ​ Chlamydia does not seem to be efficient at colonizing the pharynx and is less likely to be found there. In men having sex with men, Chlamydia is the most common cause of rectal infections. [ 58 ]

A specific form of genital ulcers and proctitis (lymphogranuloma venereum) is also caused by Chlamydia from a less common strain of Chlamydia trachomatis .

Differentiating Tests

The absence of diplococcus on microscopic exam with sufficient WBC for a diagnosis of urethritis is suggestive of chlamydia. Commercial nucleic acid amplification test (NAAT) is usually a dual test combining both gonorrhea and chlamydia, therefore an ideal way to give a definite pathogenic diagnosis.

Diagnosis of chlamydia of the pharynx or rectum is by culture or with NAAT if available.

Diagnosis of lymphogranuloma venereum is suggested from high titers of chlamydial antibodies, NAAT positive for Chlamydia , and the typical clinical presentation.

Trichomonas

Trichomonas vaginalis is a common STI and is generally underreported. A survey of young Americans found an overall prevalence of 2.3%. [ 41 ] Common symptoms (e.g., vaginal discharge and itching) are not sufficient to distinguish gonorrhea from trichomonas.

T vaginalis is often diagnosed after failure of treatment for urethritis, in cases with negative tests for gonorrhea and Chlamydia .

Culture is the most efficacious test, but newer nucleic acid amplification tests are becoming available and will allow more rapid diagnosis. T vaginalis can be diagnosed by wet preparation from vaginal or urethral discharge but this technique has low sensitivity.

Other infectious causes of urethritis, cervicitis, pelvic inflammatory disease (PID), and epididymitis

Other microorganisms, which are sexually transmitted but are not easily diagnosed, may cause both cervicitis and urethritis. These include atypical herpes simplex recurrences, Mycoplasma genitalium , and Ureaplasma urealyticum .

PID may also be caused by a mixture of organisms.

Epididymitis may be caused by enteric gram-negative organism, especially when there is a history of insertive anal sex. It may also occur in older men (≥35 years), usually resulting from bladder outlet obstruction.

There are no specific differentiating features between these other infectious agents and gonorrhea.

No commercial tests are available for M genitalium or U urealyticum .

Suggestive symptoms with a positive antibody test to herpes simplex virus (HSV)-2 and repeated negative test results for other etiologies suggests HSV infection.

Urinary culture of gram-negative organisms may be positive in cases of epididymitis.

Candidal vaginitis or bacterial vaginosis

Does not usually involve the upper genital tract and is caused by yeast species or a disruption in normal bacterial flora (bacterial vaginosis). These types of vaginitis are not sexually transmitted.

Presents as vaginal discharge, odor, and irritation.

Wet mount microscopic examination, cultures, or smears may show Candida .

In bacterial vaginosis, clue cells may be seen on wet mount and amine whiff test may be positive.

Urinary tract infection, female

Symptoms include dysuria, hematuria, and urgency. Left untreated the ascending infection may result in pyelonephritis with flank pain and fever.

Mid-stream urine culture positive for causative infectious agent.

Urinary tract infection, male

Nonpregnant women, pregnant women, treatment approach, uncomplicated gonococcal infection.

First-line treatment is a single dose of intramuscular ceftriaxone. [ 23 ] ​ One meta-analysis found that ceftriaxone had better efficacy for uncomplicated gonorrhea compared with other antibiotics. [ 67 ] If chlamydial infection has not been excluded, patients should receive oral doxycycline for 7 days in addition to the cephalosporin. [ 23 ]

In patients with urogenital or anorectal gonorrhea who have a cephalosporin allergy, a single dose of intramuscular gentamicin plus oral azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of this regimen. [ 23 ] ​ In an asymptomatic person, a single dose of ciprofloxacin could be used if the provider is able to perform gyrase A (gyrA) testing to identify ciprofloxacin susceptibility (wild type). [ 23 ] ​​ [ 68 ] An infectious disease specialist should be consulted if there is known penicillin/cephalosporin allergy.

A single dose of oral cefixime is a suitable alternative regimen if ceftriaxone is not available. [ 23 ] ​ However, cefixime has a lower response rate and reduced susceptibility compared with ceftriaxone when used for nongenital sites. [ 23 ] ​ If chlamydial infection has not been excluded, patients should receive oral doxycycline for 7 days in addition to the cephalosporin. [ 23 ] ​

Pharyngeal infections are more difficult to treat than urogenital or anorectal infections. Cefixime has limited efficacy against pharyngeal gonorrhea, and no reliable alternative treatments are available. An infectious disease specialist should be consulted for an alternative treatment recommendation if there is an anaphylactic reaction to ceftriaxone. If chlamydial infection is also identified, patients should receive oral doxycycline for 7 days in addition to ceftriaxone. [ 23 ] ​ A test-of-cure is recommended 7-14 days after treatment regardless of the treatment regimen used for pharyngeal infections. [ 23 ] ​ Use of an antiseptic mouthwash may help with clearance of pharyngeal infections. [ 69 ] In people previously treated for gonorrhea, reinfection within 12 months ranges from 7% to 12%, and so they should be retested 3 months after treatment regardless of whether they believe their sex partners were treated. [ 70 ] [ 71 ] If retesting at 3 months is not possible, retesting should be performed within 12 months of initial treatment. [ 23 ] ​

Persistent infection after treatment may be due to reinfection or resistance/treatment failure. Patients who have persistent symptoms after treatment should be retested by culture (preferably with simultaneous NAAT). If these cultures are positive for gonococcus, isolates should be submitted for resistance testing. [ 23 ] ​

Persistent infections should be retreated with a single dose of intramuscular ceftriaxone, and an infectious disease specialist should be consulted. If chlamydial infection has not been excluded, patients should receive oral doxycycline for 7 days in addition to the cephalosporin. [ 23 ] ​

A single-dose of intramuscular gentamicin plus oral azithromycin can be used as an alternative regimen for urogenital and rectal gonorrhea, particularly if resistance to cephalosporins is suspected. [ 23 ] ​ No reliable alternative treatments are available for pharyngeal gonorrhea. [ 23 ] ​

Patients with treatment failure after receiving an alternative regimen (cefixime or gentamicin plus azithromycin) should be retreated with a single dose of ceftriaxone, with or without doxycycline if chlamydial infection has not been excluded. [ 23 ] ​

Sex partners from the preceding 60 days should be identified and treated with the same regimen. [ 23 ] ​

A test-of-cure should be done 7-14 days after retreatment. Treatment failures should be reported to the CDC through the local or state health department within 24 hours of diagnosis. [ 23 ] ​

Complicated gonococcal infection

The recommended regimen is dual therapy with single-dose intramuscular ceftriaxone plus oral doxycycline for 14 days. [ 23 ] ​

Cefoxitin (plus probenecid) may be used instead of ceftriaxone. Other parenteral third-generation cephalosporins may also be used. [ 23 ]

Metronidazole should be used in combination with doxycycline to provide extended coverage against anaerobic bacteria. [ 23 ] ​

Outpatient treatment with intramuscular and oral agents can be considered because they may be as efficacious as inpatient parenteral treatment in mild to moderate PID, but reassessment after 72 hours is recommended. [ 23 ] ​ [ 79 ]

A Cochrane review assessing CDC-recommended antibiotic regimens for PID found no conclusive evidence that one antibiotic regimen is safer or more effective than another. [ 80 ]

Signs and symptoms of severe infection include: surgical abdomen; tubo-ovarian abscess; severe illness with nausea, vomiting, and fever; inability to take oral regimen; and no response from outpatient therapy.

Hospitalization and intravenous antibiotic therapy is required. Intravenous therapy with a cephalosporin (ceftriaxone, cefotetan, or cefoxitin) plus doxycycline is the recommended first-line regimen. [ 23 ] ​ Ampicillin/sulbactam plus doxycycline or clindamycin plus gentamicin are suitable alternatives. [ 23 ] ​

If the patient can take oral medication, oral doxycycline may be preferred to intravenous doxycycline to minimize pain associated with intravenous infusion.

Metronidazole is added if there is a tubo-ovarian abscess, or suspicion of any anaerobic organism or trichomonas involvement. Metronidazole should be used with ceftriaxone as ceftriaxone is less active against anaerobic bacteria than cefotetan or cefoxitin.

Reassessment can be made at 24 to 48 hours as to whether to discontinue intravenous therapy and continue with suitable oral therapy to complete 14 days of treatment if there is clinical improvement. [ 23 ] ​ Parenteral therapy can be discontinued 24-48 hours after clinical improvement; ongoing oral therapy after the parenteral cephalosporin regimen should consist of doxycycline plus metronidazole to complete a total of 14 days of therapy. Oral clindamycin or oral doxycycline can be used after the alternative parenteral clindamycin/gentamicin regimen. [ 23 ] ​ If tubo-ovarian abscess is present, oral clindamycin or oral metronidazole should be used with doxycycline as this provides better anaerobic coverage. [ 23 ] ​

Due to the high rate of fluoroquinolone resistance, intramuscular ceftriaxone plus oral doxycycline is recommended for 10 days if epididymitis infection is suspected to be sexually transmitted (i.e., gonorrhea or chlamydia). [ 23 ] ​ Chlamydia will be covered by doxycycline.

Reassessment should be made after 48 hours.

First-line treatment is intramuscular ceftriaxone. [ 23 ] ​ Clinical studies have used a higher dose of ceftriaxone for gonococcal conjunctivitis than that used in other types of gonococcal infections. [ 81 ] There are no data for the use of oral cephalosporins in gonococcal conjunctivitis.

As gonococcal conjunctivitis is uncommon and data on treatment in adults are limited, an infectious disease specialist should be consulted.

The recommended first-line regimen is intravenous or intramuscular ceftriaxone. [ 23 ] ​ Cefotaxime is a suitable alternative regimen.

Parenteral therapy should be continued for 24 to 48 hours after substantial clinical improvement, and then the patient switched to a suitable oral regimen for at least 7 days guided by antimicrobial sensitivity testing. [ 23 ] ​

If chlamydial infection has not been excluded, patients should receive oral doxycycline for 7 days in addition to the cephalosporin. [ 23 ] ​

The recommended first-line regimen is intravenous ceftriaxone. [ 23 ]

Treatment for meningitis is continued for 10 to 14 days, and for endocarditis treatment is continued for at least 4 weeks. [ 23 ]

Neonates, infants, and children

cephalosporin monotherapy or gentamicin plus azithromycin or ciprofloxacin monotherapy

Primary Options

body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

Secondary Options

240 mg intramuscularly as a single dose

2 g orally as a single dose

500 mg orally as a single dose

800 mg orally as a single dose

It is recommended that adult patients with a suspected or confirmed diagnosis of gonorrhea be treated with a single dose of ceftriaxone. [ 23 ] ​ One meta-analysis found that ceftriaxone had better efficacy for uncomplicated gonorrhea compared with other antibiotics. [ 67 ]

A single dose of oral cefixime is a suitable alternative regimen if ceftriaxone is not available. [ 23 ] ​ However, cefixime has a lower response rate and reduced susceptibility compared with ceftriaxone when used for nongenital sites. [ 23 ] ​

In patients with urogenital or anorectal gonorrhea who have a cephalosporin allergy, one option is a single dose of intramuscular gentamicin plus oral azithromycin may be considered; however, gastrointestinal adverse effects may limit the use of this regimen. [ 23 ] ​ In an asymptomatic person, a single dose of ciprofloxacin could be used if the provider is able to perform gyrase A (gyrA) testing to identify ciprofloxacin susceptibility (wild type). [ 23 ] ​​ [ 68 ] An infectious disease specialist should be consulted for advice on management if there is known penicillin/cephalosporin allergy.

Pharyngeal infections are more difficult to treat than urogenital or anorectal infections. Cefixime has limited efficacy against pharyngeal gonorrhea, and no reliable alternative treatments are available. An infectious disease specialist should be consulted for an alternative treatment recommendation if there is an anaphylactic reaction to ceftriaxone. [ 23 ] ​ The Centers for Disease Control and Prevention recommends a test-of-cure 7-14 days after treatment regardless of the treatment regimen used for pharyngeal infections. [ 23 ] ​ Use of an antiseptic mouthwash may help with clearance of pharyngeal infections. [ 69 ] In people previously treated for gonorrhea, reinfection within 12 months ranges from 7% to 12%, and so they should be retested 3 months after treatment regardless of whether they believe their sex partners were treated. [ 70 ] [ 71 ] If retesting at 3 months is not possible, retesting should be performed within 12 months of initial treatment. [ 23 ] ​

The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission. [ 23 ] CDC: expedited partner therapy 

doxycycline

100 mg orally twice daily for 7 days

If chlamydial infection has not been excluded, patients should also receive oral doxycycline for 7 days (unless they are receiving the gentamicin plus azithromycin regimen). [ 23 ] ​

metronidazole

Metronidazole is added to the recommended drug regimen for women if there is a history of sexual abuse. [ 23 ] ​

cephalosporin plus doxycycline plus metronidazole

100 mg orally twice daily for 14 days

500 mg orally twice daily for 14 days

2 g intramuscularly as a single dose

1 g orally as a single dose

The Centers for Disease Control and Prevention recommends dual therapy with single-dose intramuscular ceftriaxone plus oral doxycycline for 14 days as first-line treatment. [ 23 ] ​ Cefoxitin (plus probenecid) may be used instead of ceftriaxone. Other parenteral third-generation cephalosporins may also be used. [ 23 ] ​

PID is the most important complication of gonorrhea in women. It may develop in up to one third of women with gonorrhea and can lead to long-term sequelae even after resolution of infection. [ 41 ] [ 42 ] The most common sequelae of PID are chronic pelvic pain (40%), tubal infertility (10.8%), and ectopic pregnancy (9.1%). [ 43 ] [ 44 ]

The management of the patient's sex partners is an important consideration to prevent reinfection and further transmission. [ 23 ] ​ CDC: expedited partner therapy 

For further details of management, please see the BMJ Best Practice topic on Pelvic inflammatory disease.

hospitalization plus intravenous antibiotic therapy

1 g intravenously every 24 hours

100 mg intravenously/orally every 12 hours

500 mg orally/intravenously every 12 hours

2 g intravenously every 12 hours

2 g intravenously every 6 hours

3 g intravenously every 6 hours

100 mg orally/intravenously every 12 hours

900 mg intravenously every 8 hours

2 mg/kg intravenously/intramuscularly as a loading dose, followed by 1.5 mg/kg every 8 hours; or 3-5 mg/kg intravenously/intramuscularly every 24 hours

Severe PID requires intravenous antibiotic therapy.

The Centers for Disease Control and Prevention recommends dual therapy with a cephalosporin (ceftriaxone, cefotetan, or cefoxitin) plus doxycycline as first-line treatment. [ 23 ] ​ If the patient can take oral medication, oral doxycycline may be preferred to intravenous doxycycline to minimize pain associated with intravenous infusion. However, ceftriaxone, cefotetan, or cefoxitin must be given intravenously. Metronidazole should be used with ceftriaxone as ceftriaxone is less active against anaerobic bacteria than cefotetan or cefoxitin. Alternative parenteral regimens include ampicillin/sulbactam plus doxycycline or clindamycin plus gentamicin. [ 23 ] ​

Reassessment can be made at 24 to 48 hours as to whether to discontinue intravenous therapy and continue with oral therapy (doxycycline) to complete 14 days of treatment if there is clinical improvement. [ 23 ] ​

switch to oral antibiotic therapy following clinical improvement

After parenteral cephalosporin regimen

100 mg orally twice daily to complete 14-day course

500 mg orally twice daily to complete 14-day course

After parenteral clindamycin/gentamicin regimen

450 mg orally four times daily to complete 14-day course

After parenteral clindamycin/gentamicin regimen with tubo-ovarian abscess

Patients should be reassessed 24 to 48 hours after treatment has begun and the decision about changing from parenteral to oral therapy, if appropriate, can be based on clinical improvement. [ 23 ] ​

Parenteral therapy can be discontinued 24 to 48 hours after clinical improvement; ongoing oral therapy after the parenteral cephalosporin regimen should consist of doxycycline plus metronidazole to complete a total of 14 days of therapy.

Oral clindamycin or oral doxycycline can be used after the alternative parenteral clindamycin/gentamicin regimen. [ 23 ] ​ If tubo-ovarian abscess is present, oral clindamycin or oral metronidazole should be used with doxycycline as this provides better anaerobic coverage. [ 23 ] ​

ceftriaxone plus doxycycline

100 mg orally twice daily for 10 days

The Centers for Disease Control and Prevention recommends intramuscular ceftriaxone plus oral doxycycline as the first-line antibiotic regimen in patients with epididymitis in which the infection is suspected to be sexually transmitted (i.e., gonorrhea or chlamydia). [ 23 ] ​ Chlamydia will be covered by doxycycline.

If the patient is suspected of having epididymitis due to enteric organisms, a fluoroquinolone could be used, but it is important to rule out gonorrhea and chlamydia first. [ 23 ] ​

Epididymitis occurs in <5% of men with gonorrhea. [ 40 ] Hospital admission is required for severe cases. Rarely epididymitis can lead to infertility or chronic inflammation. Diagnosis of the offending organism should be pursued because gram-negative rods can also be a causative agent.

For further details of management, please see the BMJ Best Practice topic on Acute epididymitis.

cephalosporin monotherapy

1 g intramuscularly as a single dose

The Centers for Disease Control and Prevention recommends intramuscular ceftriaxone as a first-line regimen. [ 23 ] ​ Clinical studies have used a higher dose of ceftriaxone for gonococcal conjunctivitis than that used in other types of gonococcal infections. [ 81 ] There are no data for the use of oral cephalosporins in gonococcal conjunctivitis.

Providers should also consider one-time lavage of the infected eye with saline solution. [ 23 ] ​

As gonococcal conjunctivitis is uncommon and data on treatment in adults are limited, an infectious disease specialist should be consulted. [ 23 ] ​

nonpregnant >45 kg: disseminated gonococcal infection

excluding meningitis and endocarditis

1 g intramuscularly/intravenously every 24 hours

1 g intravenously every 8 hours

Disseminated gonococcal infection is a serious medical condition and it is recommended that the patient be hospitalized for initial therapy. [ 23 ] ​ Treatment should be undertaken with an infectious disease specialist.

The Centers for Disease Control and Prevention recommends intramuscular or intravenous ceftriaxone as the first-line regimen. [ 23 ] ​ Cefotaxime is a suitable alternative.

Parenteral therapy should be continued for 24 to 48 hours after substantial clinical improvement, and then the patient switched to a suitable oral regimen for at least 7 days guided by antimicrobial sensitivity testing. [ 23 ] ​ Children with bacteremia or arthritis should continue parenteral therapy for 7 days. [ 23 ] ​

If chlamydial infection has not been excluded, patients should also receive oral doxycycline for 7 days. [ 23 ] ​

desensitization to penicillin/cephalosporin + interim fluoroquinolone

400 mg intravenously every 12 hours

Allergy to a specific antibiotic is a contraindication for that antibiotic. A much smaller number of patients than previously thought have cross-reactivity of penicillin antibiotics and cephalosporin as an allergy. [ 82 ] If the history of the penicillin allergy does not suggest immunoglobulin E-mediated allergy, then use of cephalosporin with close observation is warranted.

Desensitization to cephalosporins is an option if cephalosporin allergy is documented.

Fluoroquinolones can be used in the interim in adults, but should not be used in children.

with meningitis or endocarditis

1-2 g intravenously every 12-24 hours

The Centers for Disease Control and Prevention recommends intravenous ceftriaxone as the first-line regimen. [ 23 ] ​

Treatment for meningitis should be continued for 10 to 14 days; treatment for endocarditis should be continued for at least 4 weeks. [ 23 ] ​

pregnant: uncomplicated urogenital/anorectal or pharyngeal infection (excluding complicated genitourinary infection)

A single dose of intramuscular ceftriaxone is recommended as a first-line regimen in pregnant women, preferably given under direct observation. [ 23 ] ​

Consultation with an infectious disease specialist is recommended if the patient has a cephalosporin allergy or there are any other considerations that preclude treatment with this regimen.

Pharyngeal infections are more difficult to treat than urogenital or anorectal infections. The Centers for Disease Control and Prevention recommends a test-of-cure 7-14 days after treatment regardless of the treatment regimen used for pharyngeal infections. [ 23 ] ​

azithromycin or amoxicillin

500 mg orally three times daily for 7 days

If chlamydial infection has not been excluded, a single dose of azithromycin is also recommended in pregnant women. Amoxicillin is an alternative in pregnant women. [ 23 ] ​

pregnant: complicated infection

hospitalization and management by an experienced provider

Pregnant women with complicated infection (i.e., pelvic inflammatory disease, conjunctivitis, or disseminated gonococcal infection) require hospitalization and specialist management from an experienced provider.

born to a mother with gonococcal infection

ceftriaxone or cefotaxime

25-50 mg/kg intramuscularly/intravenously as a single dose, maximum 250 mg/dose

100 mg/kg intravenously/intramuscularly as a single dose

Neonates who are born to women with untreated gonococcal infections are at high risk of infections and should be treated presumptively in the absence of signs of gonococcal infection. [ 23 ] ​ The Centers for Disease Control and Prevention recommends ceftriaxone as a first-line agent.​ [ 23 ] ​ Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely.​ [ 23 ] ​ Cefotaxime can be given in neonates unable to receive ceftriaxone because of simultaneous administration of intravenous calcium.​ [ 23 ] ​ An infectious disease specialist should be consulted for advice on management if there is known penicillin/cephalosporin allergy.

with ophthalmia neonatorum

25-50 mg/kg intravenously/intramuscularly as a single dose, maximum 250 mg/dose

The Centers for Disease Control and Prevention recommends ceftriaxone as a first-line agent. Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely. [ 23 ] ​​

Cefotaxime can be given in neonates unable to receive ceftriaxone because of simultaneous administration of intravenous calcium. [ 23 ] ​​

An infectious disease specialist should be consulted for advice on management if there is known penicillin/cephalosporin allergy.

with scalp abscesses or disseminated gonococcal infection

25-50 mg/kg intravenously/intramuscularly every 24 hours

25 mg/kg intravenously/intramuscularly every 12 hours

The Centers for Disease Control and Prevention recommends ceftriaxone or cefotaxime as a first-line agent. [ 23 ] ​

Infants with scalp abscesses or disseminated gonococcal infection in the form of bacteremia or arthritis should receive treatment for 7 days. Infants with meningitis should receive treatment for 10 to 14 days.

child ≤45 kg

with uncomplicated vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

ceftriaxone

The Centers for Disease Control and Prevention recommends ceftriaxone as a first-line agent. [ 23 ] ​

It is important to consider the possibility of sexual abuse in children with gonorrhea. [ 14 ] If suspected it should be reported and child protection procedures should be followed accordingly.

with bacteremia, meningitis, endocarditis, or arthritis

50 mg/kg intravenously/intramuscularly every 24 hours, maximum 2000 mg/day

Meningitis should be treated for 10 to 14 days.

Endocarditis should be treated for at least 4 weeks.

Bacteremia and arthritis should be treated for 7 days.

recurrent/resistant: urogenital/anorectal infection or pharyngitis

repeat investigations and retreatment + report to health department

Persistent infection after treatment may be due to reinfection or resistance/treatment failure. Reinfection is a likely possibility, and partner treatment should be reinforced. [ 23 ] ​

Patients who have persistent symptoms after treatment should be retested by culture (preferably with simultaneous nucleic acid amplification test). If these cultures are positive for gonococcus, isolates should be submitted for resistance testing.

Persistent gonorrhea infections should be retreated with a single dose of intramuscular ceftriaxone, and an infectious disease specialist should be consulted. [ 23 ] ​

A single-dose of intramuscular gentamicin plus oral azithromycin can be used as an alternative regimen for urogenital and rectal gonorrhea, particularly if resistance to cephalosporins is suspected. [ 23 ] ​ High-dose oral azithromycin is commonly accompanied by nausea and vomiting in patients. No reliable alternative treatments are available for pharyngeal gonorrhea. [ 23 ] ​

A test-of-cure should be done 7 to 14 days after retreatment.

Treatment failures should be reported to the Centers for Disease Control and Prevention through the local or state health department within 24 hours of diagnosis. [ 23 ] ​

doxycycline or azithromycin

If chlamydial infection has not been excluded, patients should also receive oral doxycycline for 7 days (unless they are receiving the gentamicin plus azithromycin regimen). Pregnant women should receive a single dose of azithromycin in place of doxycycline and in addition to the cephalosporin. [ 23 ] ​

Challenges for new antibiotic therapy development

Primary prevention, secondary prevention, follow-up overview, chronic pelvic pain (resulting from pelvic inflammatory disease).

Pelvic inflammatory disease (PID) complicating gonorrhea infection may develop in up to one third of women with gonorrhea. [ 41 ] [ 42 ] The most common sequelae of PID are chronic pelvic pain (40%), tubal infertility (10.8%), and ectopic pregnancy (9.1%). [ 43 ] [ 44 ]

ectopic pregnancy (resulting from pelvic inflammatory disease)

Infertility in women (resulting from pelvic inflammatory disease), fitz-hugh-curtis syndrome.

Gonococci may spread up toward the liver causing perihepatitis, which mimics acute cholecystitis in its presentation. It resolves with antibiotic therapy.

infertility in men

Rarely epididymitis, complicating gonorrhea infection, can lead to infertility or chronic inflammation.

May be a complication of ophthalmia neonatorum.

Key Articles

Centers for Disease Control and Prevention. Gonococcal isolate surveillance project (GISP). 30 August 2021 [internet publication]. [Full Text]

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. [Abstract] [Full Text]

Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA. 2004 May 12;291(18):2229-36. [Abstract] [Full Text]

Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae - 2014. MMWR Recomm Rep. 2014;63(RR-02):1-19. [Abstract] [Full Text]

Fifer H, Saunders J, Soni S, et al. 2018 UK national guideline for the management of infection with Neisseria gonorrhoeae. Int J STD AIDS. 2020 Jan;31(1):4-15. [Abstract] [Full Text]

US Preventive Services Task Force; Davidson KW, Barry MJ, Mangione CM, et al. Screening for chlamydia and gonorrhea: US Preventive Services Task Force recommendation statement. JAMA. 2021 Sep 14;326(10):949-56.  [Abstract] [Full Text]

World Health Organization. WHO guidelines for the treatment of Neisseria gonorrhoeae. 2016 [internet publication]. [Full Text]

Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea. 18 August 2021 [internet publication]. [Full Text]

Other Online Resources

• CDC: expedited partner therapy 
• CDC: gonorrhea fact sheet

Referenced Articles

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Topic last updated: 2023-06-20

Sheldon Morris , MD, MPH

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Eva Jungmann , FRCP MSc

Consultant in Genitourinary and HIV Medicine

Archway Centre & Mortimer Market Centre

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INTRODUCTION

This topic will discuss the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of DGI. The clinical manifestations, diagnosis, and treatment of uncomplicated gonococcal infection (eg, cervicitis and urethritis) are discussed elsewhere. (See "Treatment of uncomplicated gonorrhea ( Neisseria gonorrhoeae  infection) in adults and adolescents" and "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents" and "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection" .)

EPIDEMIOLOGY

Most patients with DGI are younger than 40 years of age, although DGI can occur in any age group. Historically, DGI occurred more frequently in females than males; however, that sex ratio may be reversing, with increases in gonococcal infection in general among males, and because DGI might be more common among individuals with HIV (of whom males comprise the majority in North America and Western Europe) [ 1,4-11 ].

DGI is considered a common cause of acute polyarthralgias, polyarthritis, or oligoarthritis in young, otherwise healthy patients. Although Staphylococcus aureus is the most common cause of monomicrobial septic arthritis overall, among sexually active adults, N. gonorrhoeae is the most common causative organism [ 12 ]. Nevertheless, the overall proportion of septic arthritis cases that are due to N. gonorrhoeae is low. In case studies from Europe during the 1990s, N. gonorrhoeae was the causative organism in 1.7 percent in a series from France [ 13 ], 0.6 percent in a series from the United Kingdom [ 14 ], and 0 percent from a three-year prospective community-based study in the Netherlands [ 15 ]. In a retrospective study of 34 cases of musculoskeletal infections among intravenous drug users in Spain, N. gonorrhoeae was the causative agent in 2.9 percent [ 16 ]. The prevalence of gonococcal arthritis may be higher in the United States than in the United Kingdom [ 17 ]. Gonococcal arthritis appears to be more prevalent in more resource-limited settings, although there are limited epidemiologic studies from such regions [ 6 ].

Sexually transmitted infection rates have risen sharply among adults 55 and older, CDC data shows

Sexually transmitted infections are becoming more common in older adults.

Rates of chlamydia, gonorrhea and syphilis in people ages 55 and up more than doubled in the U.S. over the 10-year period from 2012 to 2022, according to data from the Centers for Disease Control and Prevention.

The number of syphilis cases among people ages 55 and up increased seven-fold during those 10 years, while gonorrhea cases increased nearly five-fold and chlamydia cases more than tripled during that time. 

A presentation to be delivered Thursday — part of a lead-up event to the European Congress of Clinical Microbiology and Infectious Diseases next month — warns that both doctors and older adults are overlooking the risks of STIs in this age group. 

“We talk about smoking, we talk about diet, exercise, so many things, and not about sex at all,” said Justyna Kowalska, the author of the presentation and a professor of medicine at the Medical University of Warsaw. 

The issue is not limited to the U.S. In England, surveillance data published in 2022 suggested that STI diagnoses rose 22% from 2014 to 2019 among people ages 45 and up. Chlamydia was the most common, followed by gonorrhea. 

Kowalska pointed to a few factors that may be driving up STI rates among older adults.

For one, people are living longer compared to past generations and enjoying more active lifestyles in their 60s, 70s and 80s. For many, that includes sex. A 2018 survey from AARP and the University of Michigan estimated that 40% of people ages 65 to 80 are sexually active, and nearly two-thirds are interested in sex. 

Hormone replacement therapy, which can treat symptoms of menopause, can prolong sexual desire in older women, while erectile dysfunction drugs like Viagra can help older men remain sexually active.

But older adults may not have gotten the type of sex education provided to teenagers today, according to Matthew Lee Smith, an associate professor at the Texas A&M School of Public Health.

"Back in the '30s, the '40s, the '50s, traditional school wasn’t really doing sexual education very formally," said Smith, who studies behavioral health risks in older adults.

Smith's research has shown that older adults lack some knowledge about STI transmission, symptoms and prevention.

He said doctors can be sheepish about asking older patients about their sexual activity, and older people often aren’t inclined to discuss their sex lives with peers or family members.

“No one wants to think about grandma doing this,” Smith said. “You certainly aren’t going to ask grandma if she was wearing condoms — and that’s part of the problem, because every individual regardless of age has the right to intimacy.”

Some older men may struggle with condom use, Smith said, because of either a lack of dexterity or erectile dysfunction.

What's more, he added, many older adults married at a younger age than is typical now and only had one sexual partner until they divorced or were widowed. So some might not think to use a condom, Smith said — especially since pregnancy isn’t a concern. 

Nursing homes also create opportunities for new sexual partners. The results of a U.S. survey of nursing home directors, published in 2016, found that sexual activity was common in these settings, which often have more female than male residents.

“In the heterosexual, older adult community, there’s a partner gap: Women live longer than men and there’s a larger proportion of females to men,” Smith said. “What it can lead to oftentimes is multiple partners and sharing of partners.”

Though STIs pose health risks to all age groups, older people may have a harder time clearing infections or be more susceptible to contracting them in the first place, medical experts said.

“The immune system is weaker, so you can get an infection easier, but there’s other physical things related to just sexual intimacy that make one more susceptible,” said Ethan Morgan, an assistant professor of epidemiology at The Ohio State University College of Nursing. Among women who are postmenopausal, for instance, the vaginal lining is more prone to tearing, which makes it easier for an infection to occur.

The experts stressed that doctors need to do a better job of discussing safe sex with older patients.

“We want them to have their best life," Smith said, "but we want them to have it safely."

Aria Bendix is the breaking health reporter for NBC News Digital.

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Alarming —

China has a big problem with super gonorrhea, study finds, drug-resistant gonorrhea is a growing problem—one that doesn't heed borders..

Beth Mole - Mar 28, 2024 6:12 pm UTC

Health officials have long warned that gonorrhea is becoming more and more resistant to all the antibiotic drugs we have to fight it. Last year, the US reached a grim landmark : For the first time, two unrelated people in Massachusetts were found to have gonorrhea infections with complete or reduced susceptibility to every drug in our arsenal, including the frontline drug ceftriaxone. Luckily, they were still able to be cured with high-dose injections of ceftriaxone. But, as the US Centers for Disease Control and Prevention bluntly notes: "Little now stands between us and untreatable gonorrhea."

Further Reading

While those single-digit percentages may seem low, compared to other countries they're extremely high. In the US, for instance, the prevalence of ceftriaxone-resistant strains never went above 0.2 percent between 2017 and 2021 , according to the CDC. In Canada, ceftriaxone-resistance was stable at 0.6 percent between 2017 and 2021. The United Kingdom had a prevalence of 0.21 percent in 2022.

Ceftriaxone is currently the first-line treatment for gonorrhea because Neisseria gonorrhoeae has spent the past several decades building up resistance to pretty much everything else. As the CDC notes , in the 1980s, the drugs of choice for gonorrhea infections were penicillin and tetracycline. But the bacteria developed resistance. By the 1990s, the CDC was forced to switch to a class of antibiotics called fluoroquinolones, including ciprofloxacin (Cipro). But fluoroquinolone-resistance developed, too, and resistance to Cipro is now widespread. In the early 2000s, the CDC began having to tweak the recommendations as resistance spread to new places and populations.

Resistance rising

By 2007, the agency switched to cephalosporins, including cefixime. In 2010, the CDC updated the treatment again, recommending that doctors combine cephalosporins with one of two other types of antibiotics—azithromycin or doxycycline—to try to thwart the development of resistance. But, it also was no use. Two years later, in 2012, the CDC updated recommendations when cefixime resistance developed. In 2020, azithromycin was also abandoned. The cephalosporin ceftriaxone is the last drug standing in the US to treat gonorrhea infections.

In China, the swift spread of ceftriaxone-resistance isolates is alarming. The data stems from 2,804 isolates, representing 2.9 percent of all cases reported in China during 2022. Those figures come from 13 of the country's 19 provinces. While the overall prevalence of ceftriaxone-resistance isolates was 8.1 percent among the 2,804 isolates, five of those 13 provinces had prevalence rates above 10 percent. Three provinces had prevalence rates above 25 percent. In all, 18 isolates were resistant to all the antibiotics tested except for a bygone antibiotic called spectinomycin, which is discontinued in the US and elsewhere.

The study has limitations. For one, the reported number of gonorrhea cases are very likely an undercount of actual cases. Beyond gaps in reporting, many people with gonorrhea have no symptoms and, as such, don't seek treatment. Additionally, the isolates the researchers did have represented less than 3 percent of reported cases, so it's possible the prevalence rates don't represent the isolates of the entire country. Also, the researchers didn’t have detailed case data that might help identify specific risk factors for resistance development, such as the antibiotic treatments patients had. The authors did note that antibiotics are only given by prescription in China.

"These findings underscore the urgent need for a comprehensive approach to address antibiotic-resistant N. gonorrhoeae in China, including identifying factors contributing to this high resistance rate, especially in provinces where the percentage of gonococcal isolates resistant to ceftriaxone is >10 percent," the authors write.

But they also note that this is not just an alarming finding for China but also a "pressing public health concern" for the entire world. "These resistant clones have spread internationally, and collaborative cross-border efforts will be essential to monitoring and mitigating its further spread," they write.

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Gonococcal arthritis.

Raymund Li ; Jason D. Hatcher .

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Last Update: May 29, 2023 .

• Continuing Education Activity

Gonococcal arthritis is arthritis that results from the bacteremic spread of Neisseria gonorrhoeae, a sexually transmitted pathogen. It comprises localized septic arthritis and arthritis-dermatitis syndrome. This activity reviews the evaluation and treatment of gonococcal arthritis and explains the role of the interprofessional team in managing patients with this condition.

• Outline the etiology of gonococcal arthritis.
• Review the pathophysiology of gonococcal arthritis.
• Describe the use of ceftriaxone in the treatment of gonococcal arthritis.
• Explain the importance of improving care coordination among the interprofessional team to improve outcomes for patients with gonococcal arthritis.
• Introduction

Gonococcal arthritis is a bacterial arthritis that results from the bacteremic spread of Neisseria gonorrhoeae, a sexually transmitted pathogen. It is a clinical manifestation of disseminated gonococcal infection. It comprises two major clinical forms: localized septic arthritis and arthritis-dermatitis syndrome. [1] [2] [3]

Neisseria gonorrhoeae , a gram-negative diplococcus,   is the etiologic pathogen in gonococcal arthritis. It is usually transmitted sexually and is an important cause of bacterial arthritis in sexually active adolescents. However, it may also be acquired perinatally during childbirth and may cause gonococcal infection in newborns. [4] [5]

• Epidemiology

Approximately 0.5% to 3% of patients who are infected with N. gonorrhoeae develop disseminated gonococcal infection (DGI). There is a paucity of recent epidemiologic data that looks into the incidence of DGI in patients with arthritis, but historical data in the 1980s show that N. gonorrhoeae  were associated with up to 14% of patients who have arthritis. Gonococcal arthritis is more commonly seen in young healthy individuals although it may occur in any age group. [6] [7] [8]

• Pathophysiology

Host risk factors that are associated with disseminated gonococcal infection (DGI) include complement deficiencies, menstruation, pregnancy, history of pelvic surgery, and intrauterine devices (IUD). Specific strains of N. gonorrhoeae  have virulence factors that have been associated with dissemination. These include strains containing a specific outer membrane called the porin 1A serotype that promotes resistance, diminished host inflammatory response, and host cell invasion and strains that require specific substrates for growth. It is also hypothesized that the pathogenesis of DGI may be partly immune-mediated. This is supported by the fact that the pathogen is frequently not isolated from both the synovial fluid and blood of patients with clinical manifestations of dissemination. [9]

• History and Physical

Disseminated gonococcal infection (DGI) usually comprises two major clinical syndromes: the arthritis-dermatitis syndrome and localized purulent arthritis without associated skin lesions. There are, however, patients who present with symptoms that overlap between these two classic presentations. Although localized infection of the genitourinary tract, rectum, or pharynx by N. gonorrhoeae  is a prerequisite for dissemination, patients with clinical manifestations of DGI often do not manifest symptoms of localized gonococcal infection.

• Arthritis-dermatitis syndrome: This is a form of DGI that usually comprises a triad of manifestations which include tenosynovitis, dermatitis, and polyarthralgia. It is also often associated with constitutional symptoms such as fever, chills, and body malaise. Approximately 60% developed a fever in one study in women with DGI. Tenosynovitis is a unique finding in gonococcal arthritis and is usually not seen in other forms of septic arthritis. It is demonstrated by tenderness along the flexor sheath and pain on a passive extension during a physical examination. It usually affects multiple tendons, more commonly the fingers, wrists, toes, and ankles. Polyarthralgia is typically asymmetric and may affect both large and small joints. Skin lesions occur in up to 75% of cases and are frequently seen in the trunk and extremities and usually spares the face. Although a large variety of skin lesions have been observed, DGI is most commonly associated with pustular or vesicular lesions. Other skin manifestations that occur less frequently include macules, papules, bullae, or nodules. Skin lesions are characteristically transient and may disappear after several days even without treatment.
• Localized septic arthritis: This syndrome usually presents as a monoarthritis or asymmetric oligo- or polyarthritis with pain and swelling of one or more joints. Most patients do not present with systemic symptoms such as fever or chills. Joints that are commonly affected include knees, ankles, wrist, and elbow.

A high clinical suspicion is necessary for patients who present with joint pain or swelling that is concerning for septic arthritis especially in those who are sexually active and younger than 40 years old and in certain at-risk populations such as men who have sex with men (MSM). A thorough history and physical examination including an emphasis on sexual history are needed in patients with suspected gonococcal arthritis. Menstrual history and pregnancy need to be assessed in premenopausal patients. Skin and joint examination may provide information that heightens clinical suspicion, especially in patients who present with the typical triad of tenosynovitis, arthralgia, and skin lesions. [1] [4] [10]

Definitive diagnosis of disseminated gonococcal infection (DGI) or gonococcal arthritis is made through the identification of the etiologic pathogen in a specimen taken from a non-mucosal site (such as blood, synovial fluid, or skin lesions). Microbiologic tests, however, are not always positive and in such cases, diagnosis is made clinically. A clinical diagnosis may be supported by evidence of N. gonorrhoeae infection from specimens obtained from mucosal sites. Screening for other sexually transmitted illnesses such as HIV, syphilis, and chlamydia is often recommended since these frequently co-exist with gonococcal infection.

Two sets of blood cultures should be obtained, and a positive result helps distinguish gonococcal arthritis from other pathogens that cause septic arthritis. Positive blood cultures, however, are only positive in less than one-third of cases and are more frequently seen in patients who present with arthritis-dermatitis syndrome. Specimens from mucosal sites should also be obtained and are frequently helpful in patients who have a high clinical suspicion of DGI but who have sterile synovial fluid or blood specimens. Nucleic acid amplification testing (NAAT) of either urine specimens in both men and women or vaginal swabs in women is preferred, if available. The culture of a urogenital specimen is an alternative.

In patients who demonstrate joint swelling and effusion, arthrocentesis and synovial fluid analysis should be performed. Typically, a synovial fluid analysis will show a white blood cell (WBC) count of 50,000 cells/mm3 or more; although, a cell count below 10,000 cells/mm3 is not uncommon. This may be associated with reduced glucose concentration and elevated LDH levels but these findings are non-diagnostic and of limited value. In patients who present with localized purulent arthritis, N. gonorrhoeae will be isolated in only about 50% (range of 25% to 75%) of synovial fluid specimens. This is even less in patients who present with the arthritis-dermatitis syndrome. NAAT of synovial fluid is more sensitive (greater than 75%) than culture and should be performed if available.

Obtaining skin lesion specimens is usually not done because of the difficulty of sampling and its very poor yield. The culture of skin lesions is often negative. NAAT of skin specimens may be slightly more sensitive, but this is not widely available.

• Treatment / Management

Initial management in the inpatient setting is recommended for patients with a presumptive diagnosis of disseminated gonococcal infection (DGI) or gonococcal arthritis. Ceftriaxone as a parenteral therapy, either given intravenously or intramuscularly, is the preferred initial antibiotic of choice. Intravenous administration of 1 gm every 24 hours is usually preferred in patients presenting with purulent arthritis. Doxycycline 100 mg twice a day for seven days is usually added to cover potential coinfection with Chlamydia trachomatis. Alternative antimicrobial agents include third-generation cephalosporin such as cefotaxime and ceftizoxime, which are given as 1 gm every 8 hours. A dose of azithromycin 1 g orally is an alternative to azithromycin. [11] [12] [13]

Widespread resistance to oral cephalosporins such as cefixime has been documented. Oral cephalosporins are therefore not recommended as initial therapy. Although not always possible, the microbiologic diagnosis should be attempted, and antimicrobial susceptibility testing should be performed to guide antibiotic therapy. After 1 to 2 days of clinical improvement with ceftriaxone as parenteral therapy, a seven-day course of antibiotics may be completed with daily intramuscular ceftriaxone given at 250 mg daily. Patients with septic arthritis or those who are immunocompromised or slower to respond to treatment may require a longer course of therapy (7 to 14 days). De-escalation to oral antibiotic therapy (such as cefixime, fluoroquinolones, or penicillin) may be done only in patients who do not have septic arthritis and only if culture and susceptibility results are available. However, not all laboratories are capable of performing N. gonorrhoeae  culture and sensitivity testing. In cases wherein the microbiologic diagnosis is not established, the course of therapy should be completed with a parenteral cephalosporin.

Partners of patients diagnosed with DGI within 2 months should be contacted and treated whenever possible. Patients with recurrent DGI or gonococcal arthritis will require further evaluation for complement deficiency.

Patients with a history of beta-lactam allergy are often able to tolerate ceftriaxone. Due to the absence of effective alternative parenteral agents, patients who have a history of IgE mediated hypersensitivity reaction to beta-lactams may undergo either skin testing or graded challenge testing. Patients who test positive for these tests should undergo desensitization. Those with a history of severe, non-IgE mediated reaction will require consultation with an infectious disease specialist.

Patients presenting with localized purulent arthritis should undergo joint drainage, either arthroscopically or through repeated joint aspirations until there is evidence of response such as the resolution of fever, leukocytosis, joint pain, and effusions. Open surgical drainage may be necessary if aspiration is not adequate.

• Differential Diagnosis
• Septic arthritis:  Acute purulent arthritis due to other bacteria may present similarly. They may be distinguished from gonococcal arthritis through microbiologic identification from synovial fluid culture.
• Poststreptococcal arthritis:  Acute rheumatic arthritis may present with both polyarthritis and rash. The rash, however, is transient and is typically not vesicular or pustular.
• Crystal arthropathy:  This may also present as mono- or oligo-arthritis and may be distinguished through synovial fluid analysis.
• Other inflammatory arthritis:  Rheumatoid arthritis, reactive arthritis, and psoriatic arthritis may be mistaken for gonococcal arthritis, but these disease entities are usually associated with other clinical or radiologic manifestations not seen in disseminated gonococcal infection.
• Several other infections such as Lyme disease, infective endocarditis, and certain viruses may also present with some form of joint involvement.

Disseminated gonococcal arthritis has an excellent prognosis if appropriate therapy is given. Rare complications such as meningitis, perihepatitis, osteomyelitis, and endocarditis may occur if treatment is delayed or inadequate. 

• Complications
• Joint damage
• Perihepatitis
• Endocarditis
• Osteomyelitis
• Postoperative and Rehabilitation Care

After the patient has completed treatment, re-evaluation is necessary. Patients also need to be screened for other sexually transmitted infections in 3 to 6 months. More importantly, the partners need to be contacted and treated.

• Consultations
• Orthopedic surgeon
• Infectious disease
• Enhancing Healthcare Team Outcomes

Gonococcal arthritis is ideally managed with an interprofessional team of healthcare professionals. While the acute joint problem is managed by a physician, many patients may require a short program in physical therapy to regain their joint mobility and muscle strength. The nurse should educate the patient on sexually transmitted infections and how to practice safe sex. Once a patient has been diagnosed with one STD, the nurse should inform the patient about getting tested for other STDs. The pharmacist should ensure compliance with antibiotics to ensure that full healing occurs. Finally, the social worker should recommend that the partner be examined and treated, otherwise the cycle of infection transmission will continue. [14] [15] (Level V)

When patients with gonococcal arthritis are treated with antibiotics, there is usually full recovery without any sequelae. For those who have other manifestations besides the arthritis, the prognosis may depend on the severity of the infection. For example, if a patient has gonococcal endocarditis, antibiotics may be required for 4 to 6 weeks and if the valve is damaged, valve replacement may be required. In general, complications following gonococcal arthritis are rare. [8] [16]  [Level 5]

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Disclosure: Raymund Li declares no relevant financial relationships with ineligible companies.

Disclosure: Jason Hatcher declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Li R, Hatcher JD. Gonococcal Arthritis. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Ceftriaxone-Resistant Gonorrhea — China, 2022

Weekly / March 28, 2024 / 73(12);255–259

Xiaoyu Zhu 1 ,2 ,* ; Yue Xi 1 ,2 ,* ; Xiangdong Gong, MD 1 ,2 ; Shaochun Chen, PhD 1 ,2 ,3 ( View author affiliations )

What is already known about this topic?

Gonorrhea is the fourth most reported notifiable infectious disease in China. Emergence and spread of ceftriaxone-resistant clones of Neisseria gonorrhoeae in China have posed a challenge to gonorrhea treatment.

What is added by this report?

During 2017−2022, the prevalence of antibiotic-resistant strains of N. gonorrhoeae increased in China, with resistance to ceftriaxone, the first-line treatment for gonorrhea, approximately tripling. Resistance varied by geographic region. Gonorrhea strains were resistant to other antibiotics at prevalences up to 97.6%, varying by antibiotic type.

What are the implications for public health practice?

Effective diagnosis and treatment are essential to protect the health of infected persons and prevent ongoing transmission of antibiotic-resistant gonorrhea. Identifying reasons for the spread of ceftriaxone-resistant N. gonorrhoeae in China could guide strategies, such as antibiotic stewardship, to curb the spread of resistant strains.

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Gonorrhea is a widespread sexually transmitted infection; in 2022, China reported 96,313 cases of gonorrhea, making it the fourth most common notifiable infectious disease in the country after viral hepatitis, pulmonary tuberculosis, and syphilis. The rise in prevalence in antimicrobial-resistant strains, particularly the international spread of ceftriaxone-resistant clones, poses a formidable challenge to gonorrhea control. The China Gonococcal Resistance Surveillance Program (China-GRSP), established in 1987 and covering 19 of 34 provincial-level administrative units, continuously monitors gonococcal antimicrobial resistance. In 2022, 13 China-GRSP sentinel sites collected 2,804 gonococcal isolates, representing 2.9% of all cases reported in China, and 4.1% of cases reported in the 13 participating provinces. The prevalence of Neisseria gonorrhoeae resistance to ceftriaxone was 8.1%, approximately three times the 2017 rate of 2.9%; five provinces reported >10% ceftriaxone resistance. Resistance prevalences to cefixime, azithromycin, tetracycline, penicillin, and ciprofloxacin were 16.0%, 16.9%, 77.1%, 77.8%, and 97.6%, respectively. Only one case of spectinomycin resistance was reported. These data highlight a substantial increase in ceftriaxone resistance from 2017 to 2022. Effective diagnosis and treatment and appropriate management of sex partners are essential to protect the health of infected persons and prevent ongoing transmission of gonorrhea, including transmission of resistant strains. Identifying reasons for the spread of ceftriaxone-resistant N. gonorrhoeae in China could guide strategies, such as antibiotic stewardship, to mitigate the rising resistance rate and curb the spread of resistant strains.

Introduction

Gonorrhea, a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae , remains prevalent worldwide. The World Health Organization (WHO) estimated that approximately 82.4 million new gonorrhea cases were diagnosed among persons aged 15–49 years in 2020. † In China, a total of 96,313 gonorrhea cases were reported in 2022, representing a rate of 6.83 reported cases per 100,000 population, the fourth highest among class A and class B notifiable infectious diseases § in the country, ¶ after viral hepatitis, pulmonary tuberculosis, and syphilis. In the United States, in 2022, a total of 648,056 cases of gonorrhea were reported.**

In recent years, gonococcal resistance to multiple antibiotics has emerged ( 1 ). Ceftriaxone is recommended as the first-line treatment option for gonorrhea in China (single dose of 1 g, administered intramuscularly) †† as well as in the United States (single dose of 500 mg for persons weighing <150 kg, administered intramuscularly). §§ However, the emergence of ceftriaxone-resistant strains, particularly the ceftriaxone-resistant clone FC428 ( 2 ), has been identified worldwide. First identified in Beijing in 2016 ( 3 ), this resistant clone has become widely disseminated across various regions of China, with its proportion among all resistant clones steadily increasing since 2016, highlighting the challenge associated with addressing gonococcal resistance ( 4 ).

The China Gonococcal Resistance Surveillance Program (China-GRSP), established in 1987, monitors gonococcal resistance to azithromycin, cefixime, ceftriaxone, ciprofloxacin, penicillin, spectinomycin, and tetracycline in China ( 5 ). This report describes gonococcal resistance surveillance data from China for 2022, the most recent year for which data are available.

In 2022, China-GRSP conducted gonococcal resistance surveillance across 13 of the 19 provinces (among 34 national province-level administrative jurisdictions) that participate in the program, within six of seven regions of China (Supplementary Figure, https://stacks.cdc.gov/view/cdc/150923 ). N. gonorrhoeae isolates obtained from urethral (from males) or endocervical (from females) swab specimens were collected from the 2,804 identified cases included in the surveillance program from consecutively evaluated patients throughout the year. Consecutive evaluation involved specimen collection at each sentinel site from January through December, with some sites having larger sample sizes and sampling limitations that might result in data collection ending as early as September. Specimens were cultured on selective gonococcal culture media, and N. gonorrhoeae (an oxidase-positive, gram-negative diplococcus) was identified by microscopic examination of Gram-stained material, detection of a rapid oxidase reaction, and carbohydrate utilization test results. ¶¶ The susceptibility of isolates to azithromycin, cefixime, ceftriaxone, ciprofloxacin, penicillin, spectinomycin, and tetracycline was determined using the agar dilution method. Antibiotic resistance breakpoints were applied based on the European Committee on Antimicrobial Susceptibility Testing criteria,*** except for azithromycin, for which WHO criteria were used. WHO N. gonorrhoeae reference strains were used for quality assurance. The determination of antibiotic resistance was based on the minimum inhibitory concentration (MIC) values obtained through agar dilution. The antibiotic resistance breakpoints were as follows: azithromycin MIC >0.5 mg/L, cefixime MIC >0.125 mg/L, ceftriaxone MIC >0.125 mg/L, ciprofloxacin MIC >0.06 mg/L, penicillin MIC >1 mg/L, spectinomycin MIC >64 mg/L, and tetracycline MIC >1 mg/L. Resistance rate was expressed as the percentage of resistant isolates among the total number of isolates. This activity was reviewed and approved by the Medical Ethics Committee at the Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, and the National Center for AIDS/STD Control and Prevention in China.

In 2022, a total of 2,804 isolates (4.1% of 68,217 gonococcal infection cases) from 13 provinces in China were tested for antimicrobial susceptibility. The largest numbers of cases were reported in Guangdong (22,171) and Zhejiang (13,460) provinces. Rates of reported cases ranged from 2.13 to 20.58 per 100,000 population, with highest rates reported in Zhejiang, Guangdong, Yunnan, Hainan, and Guangxi provinces ( Table 1 ).

Percentages of isolates tested by province ranged from 2.1% (Yunnan) to 18.1% (Tianjin). Among isolates submitted, resistance was identified to ciprofloxacin (97.6%), penicillin (77.8%), tetracycline (77.1%), azithromycin (16.9%), cefixime (16.0%), and ceftriaxone (8.1%) ( Table 2 ). Only one isolate was resistant to spectinomycin. Among 2,804 isolates, those from 18 cases were identified as resistant to all antibiotics except spectinomycin.

Antibiotic resistance rates differed among provinces. Whereas ceftriaxone resistance detected in most sentinel sites was ≤5% during the past decade, in 2022, five provinces (Chongqing, Jiangsu, Sichuan, Tianjin, and Xinjiang) reported >10% ceftriaxone resistance, with rates in Sichuan, Tianjin, and Xinjiang surpassing 20%; only Hainan, Hunan, Shanghai, and Zhejiang reported ≤5% ceftriaxone resistance ( Figure ). Among other antibiotics, overall resistance to cefixime was 16.0%, with rates in Jiangsu, Sichuan, Tianjin, and Xinjiang exceeding 25%. Azithromycin resistance was >35% in Hunan and Shanghai and >20% in Chongqing, Guangdong, Tianjin, and Xinjiang. Resistance to ciprofloxacin remained consistently high nationwide (97.6%), with Hunan, Shaanxi, Shanghai, Sichuan, Tianjin, and Yunnan reaching 100%. Overall resistance to tetracycline was 77.1%, ranging from 28.3% in Tianjin to 100% in Xinjiang. Penicillin resistance was 77.8% nationwide and was >70% in most provinces; the highest penicillin resistance rate (98.2%) was reported by Shanghai province.

The prevalence of ceftriaxone resistance among gonococcal isolates in China nearly tripled since 2017, increasing from 2.9% to 8.1% in 2022; this rate is relatively high compared with that in other countries ( 1 ). For example, in 2022, the percentage of strains with reduced susceptibility to ceftriaxone (MIC >0.03 mg/L) in the United Kingdom was 0.21%. ††† According to the U.S. CDC’s Gonococcal Isolate Surveillance Project report, the prevalence of isolates exhibiting elevated ceftriaxone MICs (≥0.125 μ g/mL) fluctuated at approximately 0.2% during 2016−2020. §§§ In Canada, prevalence of decreased susceptibility to ceftriaxone has remained relatively stable, at approximately 0.6% during 2017–2021 ( 6 ).

These findings underscore the urgent need for a comprehensive approach to address antibiotic-resistant N. gonorrhoeae in China, including identifying factors contributing to this high resistance rate, especially in provinces where the percentage of gonococcal isolates resistant to ceftriaxone is >10%. Factors that could contribute to ceftriaxone resistance include spread of the ceftriaxone-resistant FC428 strain, gaps in gonorrhea screening, treatment, and partner management, and nonrecommended prescribing or use of antibiotics (although antibiotics are only available by prescription in China). Understanding these factors is crucial to guiding the development and implementation of targeted interventions and preventive measures. The preliminary investigation revealed that the widespread dissemination of ceftriaxone-resistant FC428 clones might be the underlying reason for the high resistance rate in China ( 3 , 4 , 7 ), although whole-genome sequencing of isolates collected in 2022 is ongoing. These resistant clones have spread internationally ( 8 – 10 ), and collaborative cross-border efforts will be essential to monitoring and mitigating its further spread. These findings also reinforce the pivotal role of programs such as the China-GRSP in the ongoing monitoring and adapting of strategies to address evolving resistance patterns. The observed resistance rates for other antibiotics emphasize the complex landscape of gonococcal antimicrobial resistance, further highlighting the urgent need to develop alternative treatment strategies, including vaccines to counter this growing threat. ¶¶¶

Limitations

The findings in this report are subject to at least four limitations. First, relying on reported cases of gonorrhea might underestimate the actual incidence, because asymptomatic cases or those among patients not seeking medical attention might go unrecorded. Second, in 2022, China-GRSP only covered one third of the country, and fewer than 3% of isolates were available for testing, leading to potential bias, and results might not be representative of the entire country. Third, this analysis focused on antimicrobial resistance rates and did not address broader sociodemographic factors influencing gonorrhea transmission. Finally, the lack of detailed patient information hampers the identification of specific risk factors contributing to the observed resistance patterns. Future research should address these limitations for a more nuanced understanding of N. gonorrhoeae epidemiology in China.

Implications for Public Health Practice

The increasing prevalence of ceftriaxone resistance in N. gonorrhoeae in China highlights a pressing public health concern. Effective diagnosis and treatment and appropriate management of sex partners are essential to protect the health of infected persons and prevent ongoing transmission of gonorrhea, including transmission of resistant strains. Public health practitioners should prioritize assessment of screening practices, particularly in regions with higher reported rates of gonorrhea cases and resistance rates. Understanding the factors that could contribute to the spread of resistance, such the nonrecommended use of antimicrobials, is also crucial to guide prevention efforts. Collaborative efforts and ongoing surveillance to monitor the international spread of resistant strains, as exemplified by programs like China-GRSP, are vital for a global response. International collaboration and information sharing are critical to prevent the further cross-border spread of resistant strains and to identify alternative treatment options for gonorrhea. Given the identified limitations, future research should aim to broaden surveillance coverage, incorporate detailed patient information, and conduct a comprehensive analysis of sociodemographic factors. These efforts could improve understanding of gonococcal infections and antibiotic resistance in China. The findings underscore the dynamic nature of this public health issue, emphasizing the ongoing need for adaptive and collaborative approaches to address the growing threat of antibiotic-resistant N. gonorrhoeae effectively.

Acknowledgments

Members of China-Gonococcal Resistance Surveillance Program; Fundamental Research Operations of the Central-Level Public Welfare Research Institute of the Chinese Academy of Medical Sciences; Jiangsu Provincial Medical Key Laboratory for Jiangsu Province Capability Improvement Project Through Science, Technology, and Education.

Corresponding author: Shaochun Chen, [email protected] .

1 Hospital for Skin Diseases, Institute of Dermatology, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China; 2 National Center for AIDS/STD Control and Prevention, Chinese CDC, Nanjing, China; 3 School of Public Health, Nanjing Medical University, Nanjing, China.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. All authors report support from the Chinese Academy of Medical Sciences for Fundamental Research Operations of the Central-Level Public Welfare Research, and from the Jiangsu Provincial Medical Key Laboratory for Jiangsu Province Capability Improvement Project through Science, Technology, and Education. No other potential conflicts of interest were disclosed.

* These authors contributed equally to this report.

† https://www.who.int/news-room/fact-sheets/detail/gonorrhoea-(neisseria-gonorrhoeae-infection)

§ Two class A and 28 class B notifiable infectious diseases are recognized in China; class A diseases include cholera and plague, and class B diseases include those associated with a high risk for outbreaks or that are likely to result in rapid spread once an outbreak occurs, such as AIDS, gonorrhea, measles, syphilis, and tuberculosis.

¶ http://www.nhc.gov.cn/guihuaxxs/s3585u/202309/6707c48f2a2b420fbfb739c393fcca92.shtml ; data on rates of reported cases of COVID-19 were not available; therefore, SARS-CoV-2 infections were not included in these statistics.

** https://www.cdc.gov/std/statistics/2022/overview.htm#Gonorrhea

†† https://doi.org/10.1097/JD9.0000000000000072

§§ https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm

¶¶ https://www.who.int/publications/i/item/9789241505840

*** www.eucast.org/clinical_breakpoints/

††† https://www.gov.uk/government/publications/gonococcal-resistance-to-antimicrobials-surveillance-programme-grasp-report/grasp-report-data-to-june-2023

§§§ https://www.cdc.gov/std/statistics/gisp-profiles/default.htm

¶¶¶ https://www.who.int/publications-detail-redirect/9789240039827

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• Day M, Pitt R, Mody N, et al. Detection of 10 cases of ceftriaxone-resistant Neisseria gonorrhoeae in the United Kingdom, December 2021 to June 2022. Euro Surveill 2022;27:2200803. https://doi.org/10.2807/1560-7917.ES.2022.27.46.2200803 PMID:36398578

* Data from 13 of 19 provincial sentinel surveillance sites were included in the analysis; only 2,804 isolates were tested for antimicrobial susceptibility, accounting for 4.1% of all reported cases in the 13 participating provinces. † Per 100,000 population.

Abbreviation: MIC = minimum inhibitory concentration. * Data from 13 of 19 provincial sentinel surveillance sites were included in the analysis. † Concentrations listed are the MIC thresholds used to categorize resistant isolates.

FIGURE . Reported rates of ceftriaxone resistance — 13 Gonococcal Resistance Surveillance Program sentinel sites,* China, 2022

Abbreviation: GRSP = Gonococcal Resistance Surveillance Program.

* Data from 13 of 19 provincial sentinel surveillance sites were included in the analysis.

Suggested citation for this article: Zhu X, Xi Y, Gong X, Chen S. Ceftriaxone-Resistant Gonorrhea — China, 2022. MMWR Morb Mortal Wkly Rep 2024;73:255–259. DOI: http://dx.doi.org/10.15585/mmwr.mm7312a2 .

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