Asymptomatic MSM should be screened for pharyngeal and anorectal gonococcal infection at least once a year, with up to 3 monthly screening of higher risk men as part of comprehensive testing for other STI and HIV. This should include pharyngeal and anal swabs for gonorrhoea..Urethral gonorrhoea usually presents with discharge but can be asymptomatic in some men.
Screening of sexually active heterosexual men for gonorrhoea is recommended because of the increasing incidence of this infection in the heterosexual population in Victoria. This should be performed using urine NAAT for gonorrhoea and chlamydia.
Men who present with urethral discharge, particularly purulent discharge and/or where there is risk for gonorrhoea (e.g. MSM, overseas contact, contact with gonorrhoea) should be tested for gonorrhoea using urine NAAT. If NAAT is used a swab of the discharge for culture should also be obtained at presentation prior to treatment for antimicrobial susceptibility testing.
Screening of sexually active heterosexual women for gonorrhoea is recommended because of the increasing incidence of this infection in the heterosexual population in Victoria..
Women can be tested by NAAT using a vaginal or endocervical swab or first pass urine . If gonorrhoea NAAT is positive then a swab for gonorrhoea culture should be obtained for antimicrobial susceptibility testing prior to treatment
Women who present with vaginal discharge should be examined for signs of cervical inflammation and tested for gonorrhoea, especially where there is increased risk for gonorrhoea (overseas contact, contact with gonorrhoea). Please refer to MSHC treatment guideline on vaginal discharge for other relevant tests in women with discharge.
Where microscopy is available, microscopy can help confirm a diagnosis of gonorrhoea, and therefore guide treatment at the initial visit, by identifying gram negative (intracellular) diplococci (GNDC) in a gram stain of the discharge. GNDC are virtually always seen in discharges from men with urethral gonorrhoea, but less frequently in cases of gonococcal cervicitis or proctitis.
Note that Neisseria meningitidis, though an uncommon cause of urethritis and cervicitis can cause a purulent discharge clinically indistinguishable from gonorrhoea. GNDC seen in meningococcal discharges are morphologically identical to gonococci.
Recommendations on the treatment of gonorrhoea are changing because of the development of antimicrobial resistance by N. gonorrhoeae. Resistance to ciprofloxacin and penicillin is now common in Victoria. Authorities now recommend combination treatment using ceftriaxone and azithromycin. If an individual reports anaphylaxis or severe allergy to cephalosporins or penicillin, advice on alternative treatment should be obtained from a sexual health specialist.
For uncomplicated urethral, cervical, pharyngeal and rectal gonorrhoea use:
Ceftriaxone 500 mg in 2 ml of 1% lignocaine as a single intramuscular injection plus
- Azithromycin 1 gram as a single dose
Please note that for uncomplicated oropharyngeal gonorrhoea, Azithromycin 2 g as a single dose is recommended
Note:If a result on a gonorrhoea culture test is received prior to treatment being administered and this result shows sensitivity to ciprofloxacin, ciprofloxacin 500mg orally ( stat) can then be used instead of ceftriaxone and azithromycin. However it is not recommended that treatment is delayed waiting for sensitivities.
Severe cases of gonococcal epididymo-orchitis should be admitted to hospital for intravenous therapy. For mild to moderate cases:
- Azithromycin 1 gram as a single dose plus
- Ceftriaxone 500mg in 2ml of 1% lignocaine by intramuscular injection* plus either
- Doxycycline 100mg twice daily for 14 days
*Men with gonococcal epididymo-orchitis should be reviewed closely: further doses of ceftriaxone may be warranted.
Severe cases of gonococcal PID should be admitted to hospital for intravenous therapy. For mild to moderate cases:
- Azithromycin 1 gram as a single dose plus
- Ceftriaxone 500mg in 2ml of 1% lignocaine by intramuscular injection** plus
- Metronidazole 400mg twice daily for 14 days plus either Doxycycline 100mg twice daily for 14 days
**Women with gonococcal PID should be reviewed closely: further doses of ceftriaxone may be warranted.
MSHC does not recommend performing a test of cure (TOC) following treatment for gonorrhoea routinely. However, a repeat test should be performed if treatment failure is suspected or if a treatment other than those recommended are used. A TOC that is positive in the absence of sexual re-exposure suggests potential treatment failure.
If a NAAT test is used for test of cure it should be performed at 14 days after treatment ( and not before in view of the possibility of DNA detection from non-viable organisms).
If NAAT positive, culture should be performed for antimicrobial resistance. Suspected treatment failures involving gonorrhoea isolates resistant to ceftriaxone and/or azithromycin should be discussed with a sexual health specialist. Individuals who are sexually active following treatment for gonorrhoea may be at risk of re-infection by untreated partners or new partners and should be encouraged to have repeated screening.
Partner notification should be discussed with patients diagnosed with gonorrhoea as sex with untreated gonorrhoea infected partners can result in repeat infection. Consider referring patients to the Let Them Know website (www.letthemknow.org.au) which is designed to support patients to undertake partner notification and which facilitates sending of SMS and email messages to partners. Partners should be contacted and tested for gonorrhoea.
Testing should include swabbing the pharynx for gonorrhea of both heterosexual males and females.. Treatment is usually provided to contacts only if the test returns a positive result. Individuals should abstain from sex with their partners until 7 days after both have received treatment.
Gonorrhoea is notifiable to the Victorian Health Department and a notification form should be completed.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.
Last Updated July 2019