7.05 Gonorrhea (Clap)

agk’s Library of Common Simple Emergencies

Presentation

A young man may present with symptoms of urethritis (dysuria, discharge), or perhaps prostatitis (low back pain) or epididymitis (scrotal pain). A young woman may have cervicitis or pelvic infection (low abdominal pain, dysuria, discharge). Both sexes may present with gonococcal proctitis (rectal pain, rectal discharge, tenesmus) or pharyngitis.

What to do:

• Obtain a sexual history and look for rash, arthritis, tenosynovitis, perihepatitis, or pain on moving the cervix. These are signs of disseminated infection, which may require a longer course of treatment or hospital admission.
• Gram stain any discharge or exudate and examine for gram- negative diplococci ingested by polymorphonuclear leukocytes, which corroborate the diagnosis of gonorrhea (their absence does not rule out the possibility).
• Culture the throat, urethra, cervix, anus – wherever the patient is symptomatic or exposed, according to the history. To avoid killing the organism, use a special transport medium or plate immediately on room-temperature Thayer-Martin medium which will be incubated soon.
• With female patients send a urine or blood test to rule out pregnancy.
• Send blood for syphilis serology and be sure someone will review and act upon the results. Incubating primary syphilis with negative serology should be eradicated by the regimens below, but established secondary or tertiary syphilis with positive serology will require a longer course of antibiotics.
• Gonorrhea should be treated with ceftriaxone 125mg im, or for oral treatment, cefixime 400mg, ciprofloxacin 500mg or ofloxacin 400mg.
• For urethritis or pelvic infection where chlamydia is a likely pathogen, cover both possibilities by adding doxycycline 100mg bid for 7 days, or azithromycin 1000mg po once. If the patient is pregnant, use erythromycin ethyl succinate (EES) 800mg qid x7d or erythromycin base, not estolate, 500mg qid x7d.
• Instruct the patient to avoid sexual contact for five days, arrange for a followup re-examination and re-culture to ensure eradication, and report the infection, if required by law.
• Treat sexual partners of patients exposed to gonorrhea with the same antibiotic regimens (you may omit cultures).
• Instruct the patient on the correct use of the condom to prevent re-infection.

What not to do:

• Do not pretend to rule out venereal disease on the basis of a “negative” sexual history. Simply taking cultures during the physical examination is often preferable to badgering patients about intimate details they would rather not reveal.
• Do not be misled by extracellular Gram-negative diplococci, which can be among the normal flora of the pharynx or vagina. Do not send culture or serology tests unless someone will see and act on the results.

Discussion

Gonorrhea with arthritis and dermatitis requires a week of antibiotic therapy. The Centers for Disease Control update treatment recommendations every few years, incorporating changes in antibiotics and sensitivity.

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