Cephalosporin treatment failure is the persistence of N. gonorrhoeae infection despite appropriate cephalosporin treatment and is indicative of infection with cephalosporin-resistant gonorrhea in persons whose partners were adequately treated and whose risk for reinfection is low. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials (537). It can have an ⦠Appropriate chlamydial testing should be done simultaneously in neonates with gonococcal infection. 1993 May;19(2):363-77. Neonates should be tested for gonorrhea at exposed sites and treated presumptively for gonorrhea as recommended in these guidelines. Pending antimicrobial susceptibility results, treatment decisions should be made on the basis of clinical presentation. Other oral cephalosporins (e.g., cefpodoxime and cefuroxime) are not recommended because of inferior efficacy and less favorable pharmacodynamics (566,568). California state health officials are reporting an increase in disseminated gonococcal infections (DGI), which is an uncommon, but significant complication of untreated gonorrhea. Use of azithromycin as the second antimicrobial is preferred to doxycycline because of the convenience and compliance advantages of single-dose therapy and the substantially higher prevalence of gonococcal resistance to tetracycline than to azithromycin among GISP isolates, particularly in strains with elevated cefixime MICs (118,540). Data are limited regarding alternative regimens for treating gonorrhea among persons who have either a cephalosporin or IgE-mediated penicillin allergy. It typically manifests as rash, tenosynovitis, polyarthralgia. Ocular prophylaxis is warranted because it can prevent sight-threatening gonococcal ophthalmia, has an excellent safety record, is easy to administer, and is inexpensive. However, product inserts for each NAAT manufacturer must be carefully consulted because collection methods and specimen types vary. Among women, gonococcal infections are commonly asymptomatic or might not produce recognizable symptoms until complications (e.g., PID) have occurred. The diagnosis often is not suspected because the initial mucosal infection is frequently asymptomatic, providing no clue to an infectious etiology. Disseminated gonococcal infection is most common in young women but may develop in sexually active persons of any age. Saving Lives, Protecting People, 2015 Sexually Transmitted Diseases Treatment Guidelines, Gonococcal Infections in Adolescents and Adults, Gonococcal Infections Among Infants and Children, www.cdc.gov/std/gonorrhea/arg/specimen_shipping_instructions1-29-08.pdf, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, HIV Infection: Detection,Counseling and Referral, Diseases Characterized by Genital, Anal, or Perianal Ulcers, Management of Persons Who Have a History of Penicillin Allergy, Diseases Characterized by Urethritis and Cervicitis, Diseases Characterized by Vaginal Discharge, Terms and Abbreviations Used in This Report, Screening Recommendations Referenced in Treatment Guidelines and Original Recommendation Sources, U.S. Department of Health & Human Services, Treat with one of the regimens recommended for adults (see Gonococcal Infections). Gentamicin ophthalmic ointment has been associated with severe ocular reactions in neonates and should not be used for ocular prophylaxis (584,585). The duration of treatment of DGI has not been systematically studied and should be determined in consultation with an infectious-disease specialist. Health departments should prioritize notification and culture evaluation for sexual partner(s) of persons with N. gonorrhoeae infection thought to be associated with cephalosporin treatment failure or persons whose isolates demonstrate decreased susceptibility to cephalosporin. Symptoms that persist after treatment should be evaluated by culture for N. gonorrhoeae (with or without simultaneous NAAT), and any gonococci isolated should be tested for antimicrobial susceptibility. Because increasing MICs might predict the emergence of resistance, GISP established lower cephalosporin MIC breakpoints than those set by CLSI to provide greater sensitivity in detecting declining gonococcal susceptibility for surveillance purposes. They tend ⦠Obstet Gynecol. 2012 Nov 15;86(10):931-8 full-text , correction can be found in Am Fam Physician 2013 Feb 1;87(3):163 Bignell C, Unemo M; European STI Guidelines Editorial Board. Infants who have gonococcal ophthalmia should be managed in consultation with an infectious-disease specialist. However, monotherapy is no longer recommended because of concerns over the ease with which N. gonorrhoeae can develop resistance to macrolides, and because several studies have documented azithromycin treatment failures (546,571-574). A major difficulty in the treatment of gonococcal infections is the increasing incidence of multidrug-resistant strains. USA.gov. Epub 2013 May 23. When treating for the arthritis-dermatitis syndrome, the provider can switch to an oral agent guided by antimicrobial susceptibility testing 24–48 hours after substantial clinical improvement, for a total treatment course of at least 7 days. In the United States, gonococcal arthritis is the most common form of septic arthritis. Complications such as pelvic inflammatory disease (PID) and disseminated gonococcal infection (DGI) occur more often in females, probably because of delays in diagnosis and treatment. In addition, U.S. gonococcal strains with elevated MICs to cefixime also are likely to be resistant to tetracyclines but susceptible to azithromycin (540). 2015 Mar;47(1):60-3. doi: 10.3947/ic.2015.47.1.60. If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated. Rather than signaling treatment failure, most of these infections result from reinfection caused by failure of sex partners to receive treatment or the initiation of sexual activity with a new infected partner, indicating a need for improved patient education and treatment of sex partners. [Dermatitis or arthritis as a sign of gonorrhoea]. However, during 2006–2011, the minimum concentrations of cefixime needed to inhibit in vitro growth of the N. gonorrhoeae strains circulating in the United States and many other countries increased, suggesting that the effectiveness of cefixime might be waning (118,540). Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Either of these regimens might be considered as alternative treatment options in the presence of cephalosporin allergy. Subgroups of MSM are at high risk for gonorrhea infection and should be screened at sites of exposure (see MSM). CDC anticipates that rising cefixime MICs soon will result in declining effectiveness of cefixime for the treatment of urogenital gonorrhea. Clinical triad (arthritis-dermatitis syndrome) Polyarthralgias: migratory, asymmetric arthritis that may become purulent Infants at increased risk for gonococcal ophthalmia include those who did not receive ophthalmia prophylaxis and whose mothers had no prenatal care or have a history of STDs or substance abuse. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection. For more information, see appropriate treatment sections under Gonoccocal Infections. With this approach, provision of medication must be accompanied by written materials (93,95) to educate partners about their exposure to gonorrhea, the importance of therapy, and when to seek clinical evaluation for adverse reactions or complications. Prompt identification and treatment are essential to prevent complications such as endocarditis, meningitis, perihepatitis and ⦠The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. NAAT allows for the widest variety of FDA-cleared specimen types, including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women). EPT should not be considered a routine partner management strategy in MSM with gonorrhea because of a high risk for coexisting infections (especially HIV infection) and because no data exist on efficacy in this population. Detection of gonococcal infection in neonates who have sepsis, arthritis, meningitis, or scalp abscesses requires cultures of blood, CSF, and joint aspirate. COVID-19 is an emerging, rapidly evolving situation. The diagnosis of gonococcal arthritis or DGI is also secure if a mucosal gonococcal infection is documented in the ⦠Infants who have ophthalmia neonatorum should be managed in consultation with an infectious-disease specialist. Appropriate chlamydial testing should be done simultaneously from the inverted eyelid specimen (see Ophthalmia Neonatorum Caused by C. trachomatis). In the United States, the proportion of isolates in GISP demonstrating decreased susceptibility to ceftriaxone or cefixime has remained low; during 2013, no isolates with decreased susceptibility (MIC >0.5 ug/mL) to ceftriaxone or cefixime were identified (118). Providers should instruct patients to refer partners with whom they have had sexual contact in the past 60 days for evaluation, testing, and presumptive treatment (see Gonococcal Infection, Management of Sex Partners). Gonorrhea is the second most commonly reported communicable disease (118). Most gonococcal infections of the pharynx are asymptomatic and can be relatively common in some populations (505,506,575,576). If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care within 12 months following initial treatment. Suspected treatment failure should be reported to CDC through the local or state health department within 24 hours of diagnosis. When cephalosporin allergy or other considerations preclude treatment with this regimen and spectinomycin is not available, consultation with an infectious-disease specialist is recommended. CDC has created the DGI Case Report Form and REDCap Survey, which state and local health Consider one-time lavage of the infected eye with saline solution. Disseminated gonococcal infection (DGI), also called the arthritis-dermatitis syndrome, reflects bacteremia and typically manifests with fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions.In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. Alternative names: Disseminated gonococcal infection (DGI); Disseminated gonococcemia; Septic arthritis â gonococcal arthritis. HHS NIH Annual screening for N. gonorrhoeae infection is recommended for all sexually active women aged <25 years and for older women at increased risk for infection (e.g., those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI) (108). Some laboratories have met CLIA regulatory requirements and established performance specifications for using NAAT with rectal and oropharyngeal swab specimens that can inform clinical management. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Disseminated Gonococcal Infection (DGI) This results from gonococcal bacteremia and only occurs in up to 3% of those with gonorrhea. Ideally, ointment should be applied using single-use tubes or ampules rather than multiple-use tubes. Gonococcal bacteremia is more likely to be associated with polyarthralgias and skin lesions. Antimicrobial resistance prediction and phylogenetic analysis of Neisseria gonorrhoeae isolates using the Oxford Nanopore MinION sequencer. Ceftriaxone treatment failures for pharyngeal infections have been reported in Australia (553,554), Japan (555), and Europe (556,557). Disseminated Gonococcal Infection List of authors. Antimicrobial susceptibility testing of all isolates should be performed. All children found to have gonococcal infections should be tested for C. trachomatis, syphilis, and HIV. It causes the sexually transmitted genitourinary infection gonorrhea as well as other forms of gonococcal disease including disseminated gonococcemia, septic arthritis, and gonococcal ophthalmia neonatorum. The classic presentation of DGI is an arthritis-dermatitis (tenosynovitis) syndrome. For more information, see Gonococcal Infections, Management of Sex Partners. Silver nitrate and tetracycline ophthalmic ointment is no longer manufactured in the United States, bacitracin is not effective, and povidone iodine has not been studied adequately (582,583). NLM doi: 10.1371/journal.ppat.1003373. In 1986, the Gonococcal Isolate Surveillance Project (GISP), a national sentinel surveillance system, was established to monitor trends in antimicrobial susceptibilities of urethral N. gonorrhoeae strains in the United States (538). Strain-specific differences in Neisseria gonorrhoeae associated with the phase variable gene repertoire. Reflecting concern about emerging gonococcal resistance, CDC’s 2010 STD treatment guidelines recommended dual therapy for gonorrhea with a cephalosporin plus either azithromycin or doxycycline, even if NAAT for C. trachomatis was negative at the time of treatment (1). BMC Microbiol. Isolates with high-level cefixime and ceftriaxone MICs (cefixime MICs 1.5–8 µg/mL and ceftriaxone MICs 1.5–4 µg/mL) have been identified in Japan (555), France (549), and Spain (559,560). Case report and review of literature]. Educational materials for female partners should include information about the importance of seeking medical evaluation for PID (especially if symptomatic); undertreatment of PID in female partners and missed opportunities to diagnose other STDs in women are of concern. To maximize adherence with recommended therapies and reduce complications and transmission, medication for gonococcal infection should be provided on site and directly observed. This preparation should be instilled into both eyes of all neonates as soon as possible after delivery, regardless of whether they are delivered vaginally or by cesarean section. Although approximately 3% of all U.S. men who have gonococcal infections are sampled through GISP, surveillance by clinicians also is critical. J Infect Dis. In classic disseminated gonococcal infection (DGI), the patient presents with the triad of skin lesions, polyarthralgias, and tenosynovitis. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Specimens obtained from the conjunctiva, vagina, oropharynx, and rectum are useful for identifying the primary site(s) of infection. Gonococcal arthritis is also known as disseminated gonococcal infection. Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis) (428,431). DGI might present as sepsis, arthritis, or meningitis and is a rare complication of neonatal gonococcal infection. Gonococcal arthritis is a rare disorder. Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea. However, gastrointestinal adverse events might limit their use: 7.7% of patients treated with gemifloxacin plus azithromycin and 3.3% of patients treated with gentamicin plus azithromycin vomited within 1 hour of medication administration, necessitating retreatment with a ceftriaxone and azithromycin. Furthermore, as cefixime becomes less effective, continued used of cefixime might hasten the development of resistance to ceftriaxone, a safe, well-tolerated, injectable cephalosporin and the last antimicrobial known to be highly effective in a single dose for treatment of gonorrhea at all anatomic sites of infection. Because N. gonorrhoeae has demanding nutritional and environmental growth requirements, optimal recovery rates are achieved when specimens are inoculated directly and when the growth medium is promptly incubated in an increased CO2 environment (394). Gonococcal ophthalmia is strongly suspected when intracellular gram-negative diplococci are identified on Gram stain of conjunctival exudate, justifying presumptive treatment for gonorrhea after appropriate cultures and antimicrobial susceptibility testing for N. gonorrhoeae are performed. Disseminated gonococcal Infection (DGI), is a rare complication associated with Neisseria gonorrhoeae, and its incidence is 0.5â3%. A recent travel history with sexual contacts outside of the United States should be part of any gonorrhea evaluation. No recent studies have been published on the treatment of DGI. Potential therapeutic options are dual treatment with single doses of oral gemifloxacin 320 mg plus oral azithromycin 2 g or dual treatment with single doses of intramuscular gentamicin 240 mg plus oral azithromycin 2 g (569). N. gonorrhoeae can spread through the bloodstream and infect other parts of the body, including the joints, resulting in disseminated gonococcal infection (DGI), which occurs in 0.5% to 3% of patients infected with N. gonorrhoeae. 2013;9(5):e1003373. Disseminated gonococcal infection (DGI) frequently results in petechial or pustular acral skin lesions, asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis (581). Patients should be instructed to refer their sex partners for evaluation and treatment. For persons with suspected cephalosporin treatment failure, the treating clinician should consult an infectious-disease specialist, an STD/HIV Prevention Training Center clinical expert (http://www.nnptc.orgExternal), the local or state health department STD program, or CDC (telephone: 404-718-5447) for advice on obtaining cultures, antimicrobial susceptibility testing, and treatment. CDC twenty four seven. Epub 2010 Jul 24. Disseminated Gonococcal Infection is an infection from Neisseria gonorrhoeae, which is spread to distant parts of the body beyond the original portal of entry (usually the lower genital tract). If prophylaxis is delayed (i.e., not administered in the delivery room), a monitoring system should be established to ensure that all infants receive prophylaxis. Providers should ask their patients with urogenital or rectal GC about oral sexual exposure; if reported, patients should be treated with a regimen with acceptable efficacy against pharyngeal gonorrhea infection. Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely. Treatment for DGI should be guided by the results of antimicrobial susceptibility testing. [Isolated gonococcal tenosynovitis. In the only published study (conducted in 1989) of the treatment of gonococcal conjunctivitis among adults, all 12 study participants responded to a single 1-g IM injection of ceftriaxone (580). For heterosexual men and women with gonorrhea for whom health department partner-management strategies are impractical or unavailable and whose providers are concerned about partners’ access to prompt clinical evaluation and treatment, EPT with cefixime 400 mg and azithromycin 1 g can be delivered to the partner by the patient, a disease investigation specialist, or a collaborating pharmacy as permitted by law (see Partner Services). If evidence of disseminated gonococcal infection exists, gonorrhea culture and antimicrobial susceptibility testing should be obtained from relevant clinical sites (see DGI). Therapy for meningitis should be continued with recommended parenteral therapy for 10–14 days. Less severe manifestations include rhinitis, vaginitis, urethritis, and infection at sites of fetal monitoring. Disseminated gonococcal infections caused by Neisseria gonorrhoeae with unique nutritional requirements. Prenatal screening and treatment of pregnant women is the best method for preventing GC infection among neonates. Additional risk factors for gonorrhea include inconsistent condom use among persons who are not in mutually monogamous relationships, previous or coexisting sexually transmitted infections, and exchanging sex for money or drugs. Few antimicrobial regimens, including those involving oral cephalosporins, can reliably cure >90% of gonococcal pharyngeal infections (566,567). For more information, see Chlamydia Infection in Neonates. Neisseria gonorrhoeae, also known as gonococcus (singular), or gonococci (plural) is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. Disseminated gonococcal infection is a condition in which a common sexually transmitted organism, Neisseria gonorrhoeae, spreads through the bloodstream and causes a variety of systemic symptoms. Follow-up cultures are unnecessary. Extensive clinical experience indicates that ceftriaxone is safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of uncomplicated urogenital and anorectal and 98.9% of pharyngeal infections in clinical trials (566,567).
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