Gonorrhoea (interim guideline - for review in 2022/23)

Cause

Gonorrhoea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae

Infects endocervix, urethra, rectum, pharynx and conjunctivae
Reduced susceptibility to first-line treatment is emerging globally and is being monitored closely
Transmission is through direct inoculation onto mucosal surfaces via:
- Sexual contact (oral, vaginal or anal), particularly when saliva is used as a lubricant
- Sexual practices such as fingering, or sharing of sex toys
- From mother to baby at vaginal delivery (e.g. neonatal conjunctivitis)
Gonorrhoea is most commonly diagnosed in
- Young sexually active adults aged under 30 years
- Sexual contacts of people with gonorrhoea
- People who have multiple sexual contacts
- People who have not consistently used condoms
- Men who have sex with men (MSM)
- Māori and Pacific Peoples
Gonorrhoea is a notifiable infection

Site of infection	Signs and symptoms
Urethra	Approximately 90% of penile urethral infection is symptomatic Urethral discharge (penile urethra) Dysuria
Cervix	Up to 80% asymptomatic Vaginal discharge Dyspareunia Postcoital bleeding Intermenstrual bleeding
Anorectum	Usually asymptomatic Rectal discharge, irritation, painful defecation, disturbed bowel function
Pharynx	Usually asymptomatic
Eyes	Conjunctivitis – may be sight threatening
Complications
Pelvic inflammatory disease (PID), subfertility, ectopic pregnancy, chronic pelvic pain Adverse pregnancy outcomes e.g. chorio-amnionitis, premature rupture of membranes, neonatal conjunctivitis Disseminated disease (rare) manifested by arthritis, skin lesions, endocarditis, meningitis Epididymitis or epididymo-orchitis Prostatitis (very rarely)

Patients with possible signs or symptoms of gonorrhoea infection
Sexual contacts of people with gonorrhoea or other STIs
Before termination of pregnancy
Before intrauterine device (IUD) insertion in people at risk of STIs
Suspected epididymo-orchitis
Suspected PID
Sexually active patients aged under 30 years opportunistically when accessing health care
Men who have sex with men (MSM)
History of sexual assault or intimate partner violence
If the patient requests a sexual health check

Note: If patient is asymptomatic and is concerned about a specific recent sexual event the recommended testing interval is 2 weeks from time of last unprotected sexual intercourse

If the patient is unlikely to return and has not been previously tested, then test opportunistically at the time of presentation and offer a re-test after the appropriate window period

Beware of false positive results in low prevalence populations – discuss with microbiologist or sexual health physician if unexpected positive result

Reduced susceptibility to the first-line treatment of ceftriaxone and azithromycin is emerging globally, however is currently rare in Aotearoa New Zealand
Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to treatment

Treatment options

Infection

Recommendation

Alternative Treatment

Uncomplicated genital, pharyngeal or anorectal infection

Adult gonococcal conjunctivitis

Ceftriaxone 500 mg in 2 mL 1% lignocaine, intramuscular injection, as a single dose

PLUS

Azithromycin 1 g orally, as a single dose

Alternative treatments are not recommended because of high levels of resistance, EXCEPT for severe allergic reactions

Seek specialist advice

Special situations

Situation	Recommendation
Pregnancy	Ceftriaxone 500 mg in 2 mL 1% lignocaine, intramuscular injection, as a single dose PLUS Azithromycin 1 g orally, as a single dose Test of cure recommended 4 weeks after treatment completed Rescreen in 3^rd trimester
Allergy or contraindications	If allergy or contraindication to azithromycin: Ceftriaxone 1 g in 3.5 mL 1% lignocaine, intramuscular injection, as a single dose Seek specialist advice if allergy to ceftriaxone
Co-infection with chlamydia	Ceftriaxone 1 g in 3.5 mL 1% lignocaine, intramuscular injection, as a single dose PLUS Doxycycline 100 mg orally twice daily for 7 days Seek specialist advice if rectal co-infection and symptomatic, or refer to anorectal syndromes guideline

Advise to abstain from sex or use condoms for 1 week from the start of treatment and until 1 week after sexual contact/s have been treated
Gonorrhoea is a notifiable infection
If a patient has an IUD, leave it in place and treat as recommended. Seek specialist advice as needed
Seek specialist advice if symptomatic anorectal infection, as further testing and extended treatment may be required
Consider HIV pre-exposure prophylaxis (PrEP) if rectal gonorrhoea is diagnosed in a male or transgender person who has anal sex with men

20-50% risk of transmission per act of unprotected intercourse
Contact tracing is important to prevent re-infection and reduce transmission
All sexual contacts in the last 3 months should be notified
Most patients choose to tell contacts themselves; giving written information can be helpful
Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

Management of sexual contacts

Where the last sexual contact with the index case was within the past 2 weeks, or the contact is symptomatic, or unlikely to return for treatment, perform a full sexual health check, and treat for gonorrhoea without waiting for test results
Where the last sexual contact with the index case was over 2 weeks previously, and the contact is asymptomatic and likely to return for treatment, it would be reasonable to wait for test results, and treat only if positive
Advise contacts to abstain from sex or use condoms until results are available, and for 1 week from the start of treatment
If contacts test positive for an STI refer to specific guideline

Review in 1 week (in person or by phone):

Discuss test results
Check symptoms (if any) have resolved
Ask if any condomless sex in the week post-treatment
Check medication was completed and tolerated
Ensure notifiable contacts have been informed
Check if any risk of re-infection. Retreatment is necessary if re-exposed to an untreated contact

Test of cure

Not routinely recommended, unless in the following situations:

Pregnancy
Pharyngeal gonorrhoea

Test of cure by nucleic acid amplification test (NAAT) should be performed at least 4 weeks after treatment is completed.

Retesting:

Re-infection is common
Retesting at 3 months is recommended, to detect re-infection

Consider testing for other STIs, if not undertaken at first presentation, or retesting after the window period

Referral to or discussion with a sexual health specialist is recommended for:

Suspected antibiotic resistance, e.g. persisting symptoms after correct management
Screening and treatment of sexual contacts if clinician wishes
Allergy or contraindication to standard treatment options
Patients with anorectal symptoms that may be STI related
Complicated clinical situations for further management