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GONORRHEA INTRODUCTIONGonorrhea (GC) is a sexually transmitted disease caused by Neisseria gonorrhoeae, a gram-negative, intracellular diplococcus. It most commonly involves the cervix, urethra, rectum and pharynx. Complications include pelvic inflammatory disease, ectopic pregnancy, infertility, bartholinitis, prostatitis, epididymitis and proctitis. Gonorrhea may also invade the bloodstream leading to disseminated gonococcal infection, which is characterized by arthritis and skin lesions. If gonorrhea is transmitted to the newborn, it may result in corneal perforation and blindness.Gonorrhea genital infection is the second most reported STD in the United States and prevalence is highest in persons less than 25 years of age.SUBJECTIVE DATAMay include:Previous gonococcal infectionRecent change in sexual partnerPartner with symptoms of or infection with N. gonorrhoeaeLack of STD protection (condom use)Reports multiple sexual partners and/or partner having multiple partnersSymptoms of gonococcal infectionReports engaging in commercial sex work and drug use Report of pelvic painTesticular pain OBJECTIVE DATAMay include:Physical exam – Gonococcal infection may have no apparent clinical symptoms until the infection is advanced. Physical findings may also be similar to that of C. trachomatis.Tenderness, guarding or rigidity on abdominal palpationEnlargement, tenderness and/or redness of the Skene’s glands, urethra, and Bartholin glandsCervical motion tendernessDysuria Mucopurulent endocervical discharge, with edema, erythema and endocervical bleeding.Palpation of penis and testicles elicit tenderness and presence of urethral erythemaPurulent discharge from penis ASSESSMENTLaboratory testing: Positive urine, urethral, cervical, vaginal or rectal swab by Nucleic Acid Amplification Test (NAAT). Clients should be screened at anatomic sites of exposure for most accurate detection.All clients found to have gonorrhea should be tested for other STDs (chlamydia, syphilis, HIV).PLANTreatment:The following recommended regimen must be followed for clients with a positive test result or for treating presumptively based on client symptoms and/or sexual contact with confirmed positive partner.CDC Recommended Regimes for Uncomplicated Gonococcal InfectionsRecommended Regimens for uncomplicated gonococcal infections of the cervix, urethra, or rectum:Ceftriaxone 500 mg in a single intramuscular dose for persons <150 kg (300 lb.)For persons weighing ≥ 150 kg (300 lb.) 1 gm of IM ceftriaxone should be administered.If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 gm as a single dose is recommended to treat chlamydia.Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, or rectum if ceftriaxone is not available:Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose ORCefixime 800 mg orally as a single dose. If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 gm as a single dose is recommended to treat chlamydia.When ceftriaxone cannot be used for treating urogenital or rectal gonorrhea because of cephalosporin allergy, a single 240 mg IM dose of gentamicin plus a single 2 gm dose of azithromycin is an option.Recommended regimen for uncomplicated gonococcal infections of the pharynx:Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb.)For persons weighing ≥ 150kg (300 lb.), 1 gm of IM ceftriaxone should be administeredIf chlamydia coinfection is identified when pharyngeal gonorrhea testing is performed, providers should treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. During pregnancy, azithromycin 1 gm as a single dose is recommended to treat chlamydia.No reliable alternative treatments are available for pharyngeal gonorrhea. For persons with a history of a beta-lactam allergy, a thorough assessment of the reaction is recommended. For persons with an anaphylactic or other severe reaction (e.g., Stevens Johnson syndrome) to ceftriaxone, consult an infectious disease consultant specialist for an alternative treatment recommendation.SPECIAL CONSIDERATIONSHIV infection: Clients who have gonococcal infection and are also infected with HIV should receive the same treatment regimen as those who are HIV negative.Coinfected with C trachomatis: Clients infected with N. gonorrhoeae frequently are co-infected with C trachomatis. Current recommendations support clients with gonococcal infection also be treated routinely with a regimen that is effective against uncomplicated genital C trachomatis infection. Allergy to cephalosporins: While allergic reactions to first generation cephalosporins occur in <2.5% of person with a history of penicillin allergy and are uncommon with 3rd generation cephalosporins (e.g., ceftriaxone and Cefixime), use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis. The following alternative treatment regimen may be considered when the client has a history of such an allergy. Providers treating persons with cephalosporin or IgE-mediated penicillin allergy should consult an infectious-disease specialist. Alternative regimen for uncomplicated gonococcal infections of cervix, urethra, or rectum:If client is allergic to penicillin: Gentamicin 240 mg in a single intramuscular dose*PLUSAzithromycin 2 g orally in a single dose * Note: MDHHS does is not stock gentamicin as it is used infrequently. Clinics may obtain it from a local pharmacy. Gentamicin is commonly available in 80 mg vials. Providers experienced in the administration of this regimen recommend drawing up the three, 80mg vials into two syringes of 120 mg each.? The two shots are then administered in tandem with 2 g oral Azithromycin. A snack should be offered to avoid stomach upset due to the large Azithromycin dose. Providers have reported that the Gentamicin injections are well tolerated by clients.CLIENT EDUCATION/COUNSELING Sexual partner and any sexual contacts in the last 60 days (preceding onset of symptoms or diagnosis) must be informed of possible infection and provided written materials about the importance of seeking evaluation for any symptoms suggestive of complications (e.g., testicular pain and pelvic or abdominal pain). Timely treatment of sex partners is essential for decreasing the risk for re-infection. If indicated, Expedited Partner Treatment (EPT) can be initiated. See EPT ProtocolClients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a multiple-dose regimen. Provide Medication Information SheetProvide STD education and informationOffer other STD testingProvide current educational information on N. gonorrhoeaeProvide contraceptive information, if indicated Encourage consistent and correct condom use to reduce STD exposure.Efforts to educate partners about symptoms and to encourage partners to seek clinical evaluationFOLLOW-UP Test of cure in 7-14 days and retest in 3 months for all + pharyngeal cases regardless of the treatment regimen (p.1914 of the 2020 CDC update)Retest all positive clients 3 months after treatment to identify recent reinfection.Clients who are not retested in 3 months should be retested within the following 12 months when seeking medical care regardless of whether they believe their sex partners were treated.Clients who have symptoms that persist after treatment should be evaluated and retested as outlined above.REFERRAL Clients with multiple re-infections or persistent symptomsPregnant clients – (refer to prenatal care)REPORTING Mandated state reporting is required in MI.All positive results must be reported to the local health department. REFERENCESCDC: Sexually Transmitted Disease, 2020 2020 Update to CDC’s Treatment Guidelines for Gonococcal InfectionReportable Diseases in Michigan: A Guide for Physicians, Health Care Providers and Laboratories, 2020Reviewed/Revised: 2021 ................
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