The treatment of gonorrhoea in WA must be guided by the current antimicrobial susceptibility profile.
Treating uncomplicated gonorrhoea
Adults
Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to this treatment.
- Ceftriaxone 500 mg in 2 mL 1% lignocaine, given by intramuscular injection
AND
- Azithromycin 1 g (orally), given together as a single treatment
Pregnancy
Treatment in pregnancy is the same as non-pregnant individuals
Children
- Ceftriaxone 50 mg/kg (maximum 500 mg), giver by intramuscular injection (using the adult dilution)
AND
- Azithromycin 20 mg/kg (to a maximum of 1 g) (oral tablet or syrup), given together as a single treatment
Uncomplicated gonorrhoea excludes:
- PID
- Epididymitis
- Ophthalmic lesions
- Prostatitis
- Arthritis
- Disseminated infections.
For treatment of adults and mature minors (aged 14 years or older) with uncomplicated gonorrhoea under a Structured Administration and Supply Arrangement, see Structured Administration and Supply Arrangement - CEO of Health SASA. This is suitable for use by Registered Nurses and Aboriginal Health Practitioners employed by a health service operated or managed by a Health Service Provider of the WA Department of Health, or contracted entity.
Chlamydia co-infection
The chlamydia co-infection rate among patients with heterosexually acquired gonorrhoea is about 40%
Because of the high risk of co-infection, treat all symptomatic patients who are suspected to have gonorrhoea, for chlamydia as well.
For suspected urethral and cervical infections, azithromycin 1mg stat (with ceftriaxone 500mg IMI as for gonorrhoea infection) will be adequate.
For rectal co-infection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:
- Ceftriaxone 500mg in 2mL 1% lignocaine, given by intramuscular injection
PLUS
- Doxycycline 100mg orally, twice daily, for 7 days if asymptomatic, but 21 days if symptomatic (internationally recognised treatment)
OR
Treating gonorrhoea in other clinical situations
Allergy to penicillin
Delayed type hypersensitivity (rash)
- Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly, (Note: should not be used when the allergy to penicillin is recorded as severe and/or hypersensitivity is immediate)
AND
- Azithromycin 1 g (orally), as a single dose, given together as a single treatment
Severe or immediate type hypersensitivity (anaphylaxis, Stevens Johnson syndrome, toxic epidermal necrolysis)
- Azithromycin 2 g orally, as a single dose - may cause gastro-intestinal intolerance
- Seek advice from a sexual health specialist
Regarding ciprofloxacin
- ciprofloxacin should no longer be used for empirical treatment due to increasing resistance profiles. It should only be used when culture has demonstrated ciprofloxacin susceptibility.
- ciprofloxacin should not be used in children under 12 years or pregnant women.
Pharyngeal gonorrhoea
Adults
- Ceftriaxone 500 mg in 2 mL 1% lignocaine give by intramuscular injection
AND
- Azithromycin 2 g orally, as a single dose, given together as a single treatment
Children
- Ceftriaxone 50 mg/kg (maximum 500 mg) given by intramuscular injection (using the adult dilution)
AND
- Azithromycin 20 mg/kg to a maximum of 1g (oral tablet or syrup), as a single dose, given together as a single treatment
Special considerations
- amoxycillin monotherapy should not be used in either adults or children for gonococcal pharyngeal infections because of the difficulty in achieving an adequate concentration of antibiotic in tissues and cells.
Anorectal gonorrhoea
- Ceftriaxone 500 mg in 2 mL 1% lignocaine given by intramuscular injection
AND
- Azithromycin 1 g (orally), as a single dose, given together as a single treatment
Prophylactic treatment of neonates
- Ceftriaxone 50 mg/kg (maximum 250 mg) given by intramuscular injection, as a single dose.
Gonococcal conjunctivitis
This disease is most often sporadic due to either auto-inoculation in a person with genital gonorrhoea or from contaminated fingers or fomites (clothes, towels) from another person with genital gonorrhoea. Rarely epidemics may occur in remote communities due to non-sexual transmission from direct contact, fomites or vectors such as flies.
Gonococcal conjunctivitis should be treated as follows:
Adults
- Ceftriaxone 500 mg in 2 mL 1% lignocaine given by intramuscular injection,
AND
- Azithromycin 1 g orally, as a single dose, given together as a single treatment
PLUS
- Frequent irrigation of the eyes with saline to remove purulent discharge.
Children
- Ceftriaxone 50 mg/kg (maximum 500 mg) given by intramuscular injection (using the adult dilution)
AND
- Azithromycin 20 mg/kg to a maximum of 1g (oral tablet or syrup) given together as a single treatment
PLUS
- Frequent irrigation of the eyes with saline to remove purulent discharge.
Management of sporadic disease
A case of gonococcal conjunctivitis in a remote Aboriginal community may herald an outbreak. Gonococcal conjunctivitis in a child may indicate sexual abuse. Therefore all suspected and confirmed cases of gonococcal conjunctivitis should be notified as soon as possible to the local PHU for further investigation.
For a sporadic case of gonococcal conjunctivitis anywhere in WA all contacts should be reviewed and any suspect cases sampled and treated empirically as for the index case. In certain situations such as in remote Aboriginal communities empiric treatment of asymptomatic contacts may be undertaken immediately under the guidance of the PHU to help prevent further dissemination.
Management of an epidemic situation
Epidemics of gonococcal conjunctivitis are a public health emergency and the local PHU should be immediately notified. All confirmed and suspected cases and their asymptomatic household and family contacts should be treated immediately.
In remote Aboriginal communities in the Goldfields, Kimberley and Pilbara regions of WA, the following may be given:
- Procaine penicillin as a single dose
OR
- Amoxycillin (child: 75 mg/kg up to 3 g) orally
PLUS
- Probenecid (child >2 years: 25 mg/kg up to 1 g) orally as a single dose.
It is important that the index case and all contacts are treated within the same 24-hour period to prevent reinfection.
Neonatal
- Ceftriaxone 50 mg/kg (maximum 125 mg) intravenously or intramuscularly, daily for seven days
PLUS
- Frequent irrigation of the eyes with saline to remove purulent discharge.
Special considerations
- Mothers of neonates with gonococcal eye disease should be tested for other STIs and treated for genital gonococcal infection.
- Also test the neonate for chlamydia.
- Specialist advice should be obtained when treating people with serious penicillin allergy. These patients are at risk of anaphylaxis, collapse, breathing difficulties or urticaria if exposed to penicillin or cephalosporin.
- Contact the local PHU as soon as possible.
Treating gonorrhoea complicated by associated infections
- PID
- Epididymitis
- Ophthalmic lesions
- Prostatitis
- Septic arthritis
- Disseminated infections.
These conditions require multiple dose therapy and individualised care. Specialist advice should be sought.
PID presents with a range of mild to severe infection. The condition may closely mimic such abdominal emergencies as acute appendicitis or ectopic pregnancy. Such circumstances warrant hospitalisation, as do PID in pregnancy, inability to tolerate oral therapy, or suspected pelvic abscess.
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