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Gonorrhoea

Demonstration of gonococcal nucleic acid in first void urine or a mucosal sample is suitable for screening.
Culture is the basic diagnostic method and it also provides determination of antimicrobial sensitivity. It is obtained in clinical suspicion of gonorrhoea or always if the nucleic acid detection test is positive.
A combination of ceftriaxone and azithromycin is the drug of choice if the sensitivity of the gonococcal strain is not known.
Decreased sensitivity to ceftriaxone has been reported in some parts of the world.
Strains resistant to ceftriaxone have become more common during the recent years.
Gonorrhoea should not be treated with oral antimicrobials if the strain is not known to be sensitive to ciprofloxacin.

Caused by Neisseria gonorrhoeae (gonococcus), which is a gram-negative diplococcus.
The incidence of gonorrhoea varies considerably between countries, as does resistance to drugs.
- In 2020, the WHO estimated 82 million new gonorrhoea infections worldwide http://www.who.int/news-room/fact-sheets/detail/gonorrhoea-(neisseria-gonorrhoeae-infection).
- In the EU/EEA, gonorrhoea is (after chlamydia) the second most commonly reported sexually transmitted disease. In 2023, almost 100 000 cases of gonorrhoea infections were reported in 28 European (EU/EEA) countries, representing a 31% increase in the crude notification rate compared with 2022. The increase in the notification rate from 2014 to 2023 was 321% http://www.ecdc.europa.eu/en/publications-data/gonorrhoea-annual-epidemiological-report-2023.
  - Consirable (over 100-fold) variation exists between countries.
  - In women infections most commonly occur in the age group 20-24 years and in men in the group 25-34 years.
  - More than half of the infections were acquired in sex between men.
Concurrent gonorrhoea and chlamydia infections are common (about 20% of patients with gonorrhoea in 2020 http://www.ecdc.europa.eu/en/publications-data/gonococcal-antimicrobial-susceptibility-surveillance-2020)
Quinolone resistant strains are more and more common, and quinolones are no more recommended for the treatment of gonorrhoea.

The incubation time in men is 2-5 days after exposure, in women somewhat longer.
Infections with mild or totally absent symptoms have become more common.
In men the symptoms are urethritis and a yellowish urethral discharge; women have vaginal discharge, pain on urinating and lower abdominal pain.
Proctitis and pharyngitis often are symptomless or the symptoms are mild.

In women the most serious complication is pelvic inflammatory disease (PID Pelvic Inflammatory Disease (PID)). In men gonorrhoea may sometimes cause epididymitis Testis Pain.

Gonococcal nucleic acid detection test in the screening of gonorrhoea
- First-void urine sample or a sample taken with a swab is examined by nucleic acid probing Laboratory Testing for Chlamydia Trachomatis and Neisseria Gonorrhoeae.
- The swab sample is taken according to the location of transmission, also from the pharynx or anus if needed.
- The same sample is used to test for both gonorrhoea and chlamydial infection.
Antimicrobial sensitivity can only be determined by bacterial culture. The culture should be performed in addition to the nucleic acid detection test if the patient's history suggests gonorrhoea (partner has gonorrhoea) and/or there are clear symptoms suggesting the infection.
- The sample may be obtained with a dacron swab from the urethra, cervix, pharynx and rectum. It is placed into a special transport tube (storage at +4°C, if necessary).

If the gonococcal nucleic acid detection test is positive, a culture sample has to be obtained in order to determine antimicrobial sensitivity before any antimicrobial treatment is started.
Ceftriaxone Antibiotics for Gonorrhoea 1 g as a single dose i.m. (strains sensitive to ceftriaxone)
If the antimicrobial sensitivity is not known: ceftriaxone 1 g i.m. + azithromycin 2 g p.o.
In patients allergic to cephalosporins, gentamicin 240 mg i.m. + azithromycin 2 g p.o. may be used.
Complicated infection: ceftriaxone 1 g once daily i.m. for 3 to 5 days
The patient should abstain from sex for a period of one week and thereafter use a condom until a negative follow-up examination result has been obtained.

Special attention should be paid to tracing contacts.
A control sample after treatment is important for verifying cure.
The control sample should be collected from the anatomic sites where the infection has been detected, a first-stream urine specimen in urethritis, otherwise a mucosal sample after 3-4 weeks.
The infection is reported to the health authorities according to the local regulations.

Unemo M, Ross J, Serwin AB, et al. 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS 2020;(Oct 29):956462420949126. [PubMed]