Recommended Timing for Test of Cure After Gonorrhea Treatment
A test of cure is not recommended after treatment of uncomplicated gonorrhea with any of the recommended or alternative regimens. 1
Understanding Test of Cure vs. Retesting
The CDC guidelines make an important distinction between:
- Test of cure (TOC): Testing to detect therapeutic failure
- Retesting: Testing to detect reinfection
When Test of Cure Is NOT Needed
For uncomplicated gonorrhea treated with recommended regimens, a test of cure is not necessary. This recommendation is based on the high efficacy of recommended treatment regimens and the rapid clearance of the infection after appropriate treatment.
Special Situations Where Test of Cure IS Needed
Test of cure should be performed in specific circumstances:
- Patients with persistent symptoms after treatment
- Patients with suspected treatment failure
- Patients with pharyngeal gonorrhea treated with spectinomycin (due to its lower efficacy of 52% for pharyngeal infections) 1
In these cases, culture for N. gonorrhoeae should be performed 3-5 days after treatment, and any isolated gonococci should be tested for antimicrobial susceptibility.
Timing of Clearance After Treatment
Research studies provide insight into how quickly gonorrhea is cleared after treatment:
- Urogenital gonorrhea: Eliminated from urine within 4 hours and from mucosa within 24 hours after therapy 2
- Anogenital gonorrhea: Median time to clearance is 2 days when using RNA-based NAATs and can range from 1-7 days 3
- When using DNA-based NAATs, clearance can take 1-15 days 3
Recommended Timing for Retesting
While test of cure is not recommended for uncomplicated gonorrhea, the CDC strongly recommends retesting all patients with gonorrhea 3 months after treatment to detect reinfection. This recommendation is based on the high prevalence of reinfection observed in patients who have had gonorrhea in the preceding months 1.
If patients do not return for retesting at 3 months, providers should test them whenever they next seek medical care within the following 12 months, regardless of whether the patient believes their sex partners were treated 1.
Important Considerations for Testing Methods
When using nucleic acid amplification tests (NAATs) for testing:
- False positives can occur if testing is done too soon after treatment due to detection of dead organisms
- If a test of cure is necessary (for special situations mentioned above), using culture rather than NAAT is preferred
- If using NAATs for test of cure, wait at least 7 days for RNA-based tests or 14 days for DNA-based tests 3
Clinical Pearls and Pitfalls
- Common pitfall: Confusing test of cure with retesting for reinfection
- Important caveat: Persistent symptoms after treatment may be due to reinfection, treatment failure, or other causes such as Chlamydia trachomatis or other organisms
- Clinical pearl: Resolution of genital symptoms typically occurs within 2 days (median) after effective treatment, with 90% of patients reporting symptom resolution within 1 week 4
- Risk factor: Concurrent chlamydia infection and being female are associated with prolonged time to symptom resolution 4
Remember that the majority of infections identified after treatment with recommended regimens result from reinfection rather than treatment failure, highlighting the importance of partner treatment and patient education.