What are the complications and treatment options for gonorrhea?

Gonorrhea Complications and Treatment

Gonorrhea infection can lead to serious complications including pelvic inflammatory disease, infertility, and increased risk of HIV transmission, requiring prompt treatment with ceftriaxone 250 mg IM as a single dose plus azithromycin 1 g orally as a single dose. 1

Complications of Gonorrhea

In Women

• Pelvic Inflammatory Disease (PID): A major complication that can lead to:

  • Tubal scarring
  • Infertility (occurs in 10-15% of PID cases)
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Intra-abdominal infections 2

• Asymptomatic Infection: Many infections in women remain asymptomatic until complications develop, making screening crucial 1

In Men

• Epididymitis: Inflammation of the epididymis that can lead to:
  • Testicular pain and swelling
  • Potential infertility if untreated 1
• Urethritis: Inflammation of the urethra causing dysuria and discharge 1

In Both Sexes

• Disseminated Gonococcal Infection (DGI): Systemic spread that can cause:

  • Joint infections (septic arthritis)
  • Skin lesions
  • Endocarditis (rare but serious)
  • Meningitis (rare but serious) 3

• Facilitation of HIV Transmission: Gonorrhea increases the risk of acquiring and transmitting HIV 1, 4

• Pharyngeal and Rectal Infections: Often asymptomatic but can serve as reservoirs for continued transmission 4

Treatment Recommendations

Current First-Line Treatment

• Uncomplicated Gonorrhea:

  • Ceftriaxone 250 mg IM as a single dose, PLUS
  • Azithromycin 1 g orally as a single dose 1, 3

• Complicated Infections (PID, epididymitis, DGI):

  • Ceftriaxone 1 g IM or IV every 24 hours until improvement begins
  • Continue for 24-48 hours after improvement, then switch to oral therapy to complete at least 1 week 3
  • For PID: Add metronidazole 500 mg orally twice daily for 14 days 3, 2

Alternative Treatments

• For patients with severe cephalosporin allergy:
  • Spectinomycin 2 g IM in a single dose (less effective for pharyngeal infections) 3
  • Azithromycin 2 g as a single oral dose (but resistance concerns exist) 3

Important Treatment Considerations

1. Dual therapy is recommended to:

   • Treat possible co-infection with Chlamydia trachomatis (occurs in 10-40% of gonorrhea cases)
   • Help prevent antimicrobial resistance 1, 4, 5

2. Antimicrobial resistance:

   • Fluoroquinolones are no longer recommended due to widespread resistance
   • Oral cephalosporins (like cefixime) are no longer recommended as first-line therapy 1
   • Resistance monitoring is ongoing and may necessitate treatment changes 1, 5

3. Partner treatment:

   • All sexual partners from the past 60 days should be evaluated and treated
   • If the last sexual contact was >60 days before diagnosis, the most recent partner should be treated 1, 3

4. Test of cure:

   • Not routinely recommended if symptoms resolve after recommended treatment
   • Consider for pharyngeal infections or if alternative regimens were used 3

Special Populations

Pregnant Women

• Should receive ceftriaxone 250 mg IM plus azithromycin 1 g orally
• Fluoroquinolones and tetracyclines are contraindicated 1, 3

HIV-Infected Patients

• Should receive the same treatment regimen as HIV-negative patients 1, 3

Prevention Strategies

• Regular screening of high-risk populations:
  • All sexually active women <25 years
  • Women with new or multiple sexual partners
  • Men who have sex with men
  • People with previous STIs 4
• Consistent and correct condom use
• Partner notification and treatment
• Behavioral counseling for STI prevention 2, 4

Common Pitfalls in Management

1. Inadequate treatment of pharyngeal infections - requires ceftriaxone-based therapy
2. Failure to treat partners, leading to reinfection
3. Missing co-infections with Chlamydia trachomatis
4. Delayed treatment in asymptomatic individuals, allowing complications to develop
5. Using outdated treatment regimens that no longer effective due to antimicrobial resistance 3

Early detection through appropriate screening and prompt, effective treatment are essential to prevent the serious complications of gonorrhea infection and reduce transmission.