Treatment of Disseminated Gonococcal Infection
The recommended treatment regimen for disseminated gonococcal infection (DGI) is ceftriaxone 1 g IM or IV every 24 hours, with hospitalization for initial therapy, followed by oral therapy after clinical improvement to complete at least 1 week of total antimicrobial therapy. 1
Initial Management
Hospitalization Criteria
- Hospitalization is recommended for initial therapy, especially for:
- Patients who might not comply with treatment
- Cases with uncertain diagnosis
- Patients with purulent synovial effusions or other complications 1
Initial Assessment
- Examine for clinical evidence of endocarditis and meningitis
- Evaluate for concurrent Chlamydia trachomatis infection (treat presumptively unless testing excludes this infection) 1
Treatment Regimens
First-Line Therapy
- Ceftriaxone 1 g IM or IV every 24 hours 1
Alternative Regimens (if first-line cannot be used)
- Cefotaxime 1 g IV every 8 hours
- Ceftizoxime 1 g IV every 8 hours
- Spectinomycin 2 g IM every 12 hours 1
Important Note: Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are listed in older guidelines but should NOT be used for infections in men who have sex with men (MSM), in those with history of recent foreign travel or partners' travel, or infections acquired in areas with increased quinolone-resistant N. gonorrhoeae (QRNG) prevalence. 1
Duration and Transition to Oral Therapy
- Continue parenteral therapy for 24-48 hours after clinical improvement begins
- Then transition to one of the following oral regimens to complete at least 1 week of total antimicrobial therapy:
- Cefixime 400 mg orally twice daily
- Ciprofloxacin 500 mg orally twice daily (with same restrictions as above)
- Ofloxacin 400 mg orally twice daily (with same restrictions as above)
- Levofloxacin 500 mg orally once daily (with same restrictions as above) 1
Special Considerations
Complicated DGI (Meningitis and Endocarditis)
- For meningitis or endocarditis: Ceftriaxone 1-2 g IV every 12 hours 1
- Duration:
- Meningitis: Continue therapy for 10-14 days
- Endocarditis: Continue therapy for at least 4 weeks
- Treatment of complicated DGI should involve consultation with an infectious disease specialist 1
Management of Sex Partners
- Gonococcal infection is frequently asymptomatic in sex partners of patients with DGI
- Patients should be instructed to refer sex partners for evaluation and treatment 1
Clinical Pearls and Pitfalls
Common Pitfalls
- Failure to recognize DGI: Some strains of N. gonorrhoeae that cause DGI may cause minimal genital inflammation, making diagnosis challenging 1
- Inadequate duration of therapy: Ensure completion of full treatment course (minimum 1 week)
- Missing concurrent infections: Always treat presumptively for C. trachomatis unless testing excludes this infection 1
Monitoring
- Evaluate clinical response within 24-48 hours
- Consider joint aspiration for purulent synovial effusions
- For complicated cases (endocarditis, meningitis), more intensive monitoring is required
Antimicrobial Resistance Considerations
- Ceftriaxone remains effective for DGI with no reported treatment failures using the recommended regimens 1
- Quinolone resistance is increasing globally, limiting their use in certain populations 1
- Recent data (2022) shows ceftriaxone MICs have remained stable in the US, with <0.1% exhibiting an "alert value" MIC 2