Management of Gonococcal Infections
1 May 2018
Two cases of gonorrhoea with high level resistance to ceftriaxone, azithromycin, ciprofloxacin, penicillin and tetracycline were diagnosed in Australia in March 2018. One case had recent sex in south east Asia, the other case had no recent overseas travel so it is likely there are undetected cases. No cases have been reported in South Australia. Emergence of this gonococcal strain in Australia is of concern, as treatment is complex and may require intravenous antibiotics.
Initial investigations for suspected gonorrhoea
- Take a urine or swab for nucleic acid amplification testing (NAAT).
- Take a swab for culture from any exposed sites (urethra, cervix, pharynx, rectum) in people with symptoms (discharge, dysuria) or recent history of overseas travel.
- Following a NAAT positive test, take a swab for culture before treatment.
- Culture of Neisseria gonorrhoeae is critical for detecting antimicrobial resistance.
Treatment of gonorrhoea
- Unless known to be penicillin allergic, treat uncomplicated genital, ano-rectal or pharyngeal gonococcal infections with:
ceftriaxone 500mg IM, stat in 2mL 1% lignocaine PLUS azithromycin 1g PO, stat.
- Do not use ciprofloxacin, penicillin, tetracycline or azithromycin as single agents to treat gonorrhoea.
- Penicillin allergy is not necessarily a contraindication to ceftriaxone.
- If penicillin allergic:
- assess allergy as per the antibiotic therapeutic guidelines;
- use ceftriaxone if no history of IgE-mediated immediate allergic reaction (e.g. urticaria, angioedema, bronchospasm or anaphylaxis) or delayed type reactions (e.g. DRESS or SJS/TEN) with penicillin;
- seek specialist advice for patients with immediate type hypersensitivity reactions or delayed type reactions when given penicillin.
- Stress the importance of partner notification and treating sexual partners.
- Advise all cases to have no sexual contact for 7 days after treatment is administered.
- Advise no sex with partners from the last 2 months until the partners have been tested and treated.
- Clinical follow-up is required for effective management.
- Review in one week: to assess symptom resolution (if initially symptomatic), to confirm partner notification has occurred and to ensure testing for other STI including HIV and syphilis.
- Review at 2 weeks after treatment: to undertake test of cure by NAAT and follow-up with culture if NAAT positive.
- Review at 3 months: to test for re-infection.
- Notify the Communicable Disease Control Branch (CDCB) on ph: 1300 232 272 or fax: (08) 8226 1800.
- Immediately advise CDCB by phone of any treatment failures (clinical or culture-proven).
Seek expert advice from Clinic 275, the STI service (8222 5075) about patients with treatment failure, or who are allergic to ceftriaxone, or with complicated infection, and before using alternative treatments.
For further details see: Australian National STI guidelines