Gonorrhea Treatment and Therapy

For Gonorrhea Treatment and Therapy, what needed to be considered are the effectiveness, price, and minimal toxic effects. Management pathways is depend on the existing diagnostic facilities as seen in Table 1,2,3. The selection of treatment regimens should consider also the site of infection, strains of N. gonorrhoeae resistance to antimicrobials, and the possibility of Chlamydia trachomatis infections are occurring simultaneously. Therefore often co-infected with C. trachomatis occurs, then at an with gonorrhea are also suggested to be given simultaneously with the treatment regimen appropriate for C. trachomatis in accordance with the table number 4.

Table 4

       In addition to laboratory testing facilities, management of gonorrhea urethritis is also dependent on the incident NGPP (Neisseria gonorrhoeae producing penicillinase) strain. But when we look at the report the Centers for Disease Control (CDC) in 1989, the management pattern of gonorrhea urethritis undergone some changes due to:

1. The same high incidence of chlamydial infection with gonorrhea (25-50%).

2. Higher incidence of chlamydia and gonorrhea infection with complications

3. Difficulty chlamydia examination techniques

4. Increasing number of reports of gonorrhea strains are resistant to tetracycline.

5. More high strain report NGPP

Given the above, the CDC (1989) recommends that the treatment of gonorrhea urethritis is not used anymore penicillin or its derivatives, and in addition it is also given the drug for non-gonorrhea urethritis (chlamydia) simultaneously.

A. Recommendations Centers for Disease Control and Prevention (CDC), in 2007 in the Treatment of Gonorrhea

a. Centers for Diseases Control and Prevention (2007) recommends treatment of uncomplicated gonococcal infections as follows:

     1. I.m. Ceftriaxone 125 mg, single dose

     2. Cefixime 400 mg orally, single dose

Coupled with therapy for Chlamydia infection if the possibility of Chlamydia infection can not be ruled out:

    1. Azithromycin 1 g orally, single dose

    2. Doxycycline 100 mg orally, 2 times per day for 7 days

    Alternative medicine:

    1. Erythromycin 500 mg orally, 4 times per day for 7 days

    2. Etisuksinat Erythromycin 800 mg orally, 4 times per day for 7 days

    3. Ofloxacin 300 mg orally, 2 times per day for 7 days

    4. Levofloxacin 500 mg orally, 1 times per day for 7 days

 Alternative Medicine:

1. Spectinomycin 2 g, i.m., single dose

2. Cephalosporin single-dose ceftiozime 500 mgi.m., or cefoxitin 2 g im, PLUS probenecid 1 g orally, or cefotaxime 500 mg im Cefpodoxime 400 mg and cefuroxime axetil 1 g

Pharingeal Gonorrhea

1. Ceftriaxone 125 mg IM, single dose + Chlamydia Infection Treatment

Disseminated Gonorrhea

Treatment of disseminated gonorrhoeae is recommended:

1.Ceftriaxone 1 g i.m / I.V., Per 24-hour

2. Cefotaxime 1 g i.v., per 8 hours or

3. Cetioxime 1 g i.v., per 8 hours

4. Spectinomycin 2 g i.m., per 12 hours

Treatment for 24-48 hours after clinical improvement antibiotic therapy, at least 1 week.

    - Cefixime 400 mg / suspension (200 mg / 5 ml), oral, 2 times per day

    - Cefpodoxime 400 mg, orally, 2 times per day

 Pelvic Inflammatory Disease (PID)

a. Recommended Parenteral Regimen A

- Cefofetan 2 g i.v., per 12 hours

- Cefoxitin 2 g i.v., per 6 hours

- Doxycycline 100 mg orally or i.v., per 12 hours

b. Recommended Parenteral Regimen B

- Clindamycin 900 mg i.v., per 8 hours

- Gentamicin loading dose I.V. / I.m. (2 mg / kg), followed by maintenance dose (1.5 mg / kg) per 8-hour, single dose / day

c. alternative

- Ampicillin / Sulbactam 3 g iv every 6 hours + Doxycycline 100 mg orally or iv, per 12 hours

d. Oral treatment

- Ceftriaxone 250 mg IM, single dose + Doxycycline 100 mg orally, 2 times per day for 14 days, with or without  Metronidazole 500 mg, orally, 2 times per day for 14 days

                                     OR

- Cefoxitin 2 g IM, single dose + probenecid 1 g, oral, single dose, with or without

          - Doxycycline 100 mg, orally, 2 times per day for 14 days

          - Metronidazole 500 mg, orally, 2 times per day for 14 days

        Although it was found that the average fluoroquinolones have the same effect of treatment with ceftriaxone (Rocephin), Neisseria gonorhoeae higher resistance to fluoroquinolones in multiple geographic regions. Therefore, the CDC recommends the use of fluoroquinolones to treat gonorrhea infections in patients who live or medapat infections acquired in Asia, the Pacific (including Hawaii), and California. Note CDC recently there is increasing resistance to fluoroquinolones N.gonorrhoeae in homosexual men, and fluoroquinolones are not recommended as first-line treatment in these patients. England, Wales, and Canada reported Neisseria gonorrhoeae resistant to fluoroquinolones.

     Patients with suspected disseminated gonococcal infection should inpatient hospital (hospitalization). Evaluations include examination of clinical signs of endocarditis and meningitis. CDC recommends ceftriaxone, 1 g intravenously or intramuscularly every 24 hours, for a patient with disseminated infection. Parenteral antibiotics followed 24-48 hours after the start there was clinical improvement and then started on oral therapy.

         Fluoroquinolones and tetracyclines are contraindicated in pregnancy. If patients can not tolerate cephalosporins, alternative therapies are spectinomycin (Trobicin), 2 g intramuscularly every 12 hours. Both of these treatment regimens have the same treatment effect.

Management of sex partners

        Effective clinical management of patients undergoing treatment of STDs requires treatment on a patient's sexual partner to prevent reinfection and limit contagion wider. Sex partners of patients should undergo evaluation, examination, medication if they have sexual contact within 60 days before the symptoms experienced by patients appears. Sex partners of patients who have to undergo the final evaluation and treatment even though they have sexual contact > 60 days before symptoms appear. To avoid re-infection, patients and their sexual partners should avoid sexual intercourse until treatment is completed.

Special considerations

a. Allergy, Intolerance, and Side effects.

Patients who can not tolerate cephalosporins or quinolones should be treated with spectinomycin, Because spectinomycin unreliable (52% effective) against pharyngeal infections, patients with suspected or proven to have an infection of the pharynx should be examined pharyngeal culture 3-5 days after treatment to ensure the infection has disappeared.

b. Pregnancy

Pregnant women should not be treated with quinolones or tetracyclines. Pregnant women infected with N. gonorrhoeae should be treated with cephalosporins. Women who can not tolerate cephalosporins should receive spectinomycin 2 g im, a single dose. Either azithromycin or amoxicillin is recommended for treatment of C. trachomatis infection during pregnancy.

c. Quinolones in Adolescents

Fluoroquinolon is not recommended for individuals with age <18 years, as many studies have shown that fluoroquinolones can cause damage to blood vessels. In children with a body weight> 45 kg can be treated with the recommended dosage for adults. d. HIV infection In patients infected with gonococci and HIV-infected patients should receive the same treatment right with HIV-uninfected patients.

B. BASSH

According to the British Association for Sexual Health and HIV (BASSH) at the National Guideline on the Diagnosis and Treatment of Adults gonorrhoeae in 2005, the therapeutic indication:

a.Tes positive diagnostic

- Neisseria gonorrhoeae culture positive

- Positive nucleic acid test - confirmation of the diagnosis by culture is the main recommendation for or during treatment (grade C recommendation).

- Epidemiology, if there is confirmation of sexual partners who have gonococcal infection

Recommended treatment of uncomplicated anogenital infection in adults:

- Ceftriaxone 250 mg i.m. as a single dose or, Cefixime 400 mg orally as a single dose or, Spectinomycin 2 g im as a single dose

      N. gonorrhoeae has shown a growing capacity to reduce the sensitivity and resistance to multiple antimicrobials. Announcements experiments represent the clinical efficacy of treatment of gonorrhea in the previous era of antimicrobial sensitivity. Research data in 2004 showed a significance level of resistance to penicillin N.gonorhoeae 11.2%, 44.55% tetracycline and ciprofloxacin 14.1%.

     Alternative regimens may be used when the infection is known to be sensitive to the prevalence of antimicrobial-resistant or where they are less than 5%.

1. Ciprofloxacin 500 mg orally single dose or

2. Ofloxacin 400 mg orally single dose or

3. Ampicillin 2 g or 3 g + probenecid 1 g orally single dose

4. Other single-dose cephalosporin regimens, such as cefotaxime 500 mg im single dose or cefoxitin 2 g i.m. single dose + probenecid 1 g orally.

5. cefpodoxime is an alternative to oral medication 3rd generation cephalosporins as a single dose of 200 mg was allowed for the treatment of uncomplicated gonorrhea. The experimental data are limited, but the picture of the short half-life, slightly advantageous compared pharmacokinetic suboptimal efficacy of cefixime and pharyngeal infection, can not be recommended.

6.  Azithromycin (2 g single dose) suggests an acceptable efficacy in clinical trials, but is associated with higher gastrointestinal intolerance. Not recommended for treatment of gonorrhea.

If  Allergy with Beta-lactamase.

1. Spectinomycin 2 g i.m. single dose or

2. Ciprofloxacin 500 mg orally single dose when the infection is known or anticipated if sensitive to quinolones

Pregnancy and Breastfeeding.

Pregnant women not treated with quinolones or tetracyclines

Recommended regimens:

1. Ceftriaxone 250 mg i. m. single dose or

2. Cefixime 400 mg orally single dose or

3. Spectinomycin 2 g i.m. single dose or

4. 3 g Amoxicillin or ampicillin 2 g or 3 g + probenecid 1 g orally single dose, where there is a prevalence of penicillin-resistant N.gonorrhoeae area ≤ 5%

Pharyngeal infection.

Recommended regimens:

1. Ceftriaxone 250 mg i.m. single dose or

2. Ciprofloxacin 500 mg orally single dose N.gonorhoeae known if sensitive to quinolones

3. Ofloxacin 400 mg orally single dose N.gonorhoeae known if sensitive to quinolones

4. single-dose therapy of ampicillin or spectinomycin have low efficacy in eradicating gonococcal infections of the pharynx.

Co-infection with Chlamydia trachomatis.

Genital infection with C. trachomatis in general coincide with gonococcal genital infections (up to 20% in men and 40% in women with gonorhoeae). C. trachomatis screening is routinely performed on adult patients with gonorrhea or treatment is given to eradicate the possibility of co-infection. The combination of effective antimicrobial therapy for C. trachomatis with a single dose of gonococcal infections especially appropriate when in doubt when the patient will return for a follow-up evaluation.

Follow Up.

Assessment of patients after treatment:

- to determine the achievement of therapeutic

- to ensure resolution of symptoms

- to inquire adverse reactions

- to know the sexual history back in order to find out the possibility of re-infection

- to follow the development partners and health promotion

Microbiological tests should not be routinely performed when the infection is treated with therapy recommendations direct observation, infection is very sensitive to the administration of antimicrobial drugs, the symptoms have changed and there is no risk of re-infection. When symptomatic patients after treatment, suboptimal therapy, resistant strains are identified or there possibility re-infection, culture test is recommended. Pregnancy does not reduce the efficacy of treatment. All treatments are less effective in eradicating pharyngeal infection. Culture test done at least 72 hours after completion of treatment and 2 weeks after treatment NAATs.

C. Recommendations of the World Health Organization (WHO) in the Treatment of Gonorrhea

According to the World Health Organization, 2001, the standard treatment of gonorrhea:

1. The First-line drug

3rd generation cephalosporin is recommended cefixime (oral, 400 mg single dose) or ceftriaxone (im, 125 mg single dose). Recommended class of quinolones: ciprofloxacin (oral, 500 mg single dose). Spectinomycin (im, 2 g single dose) is the longest antibiotic used for the treatment of gonorrhea.

2. Second-and third-line agents

Penicillin is often given a single dose of amoxicillin (oral, 3 g) or ampicillin (oral, 3 g). Ampicillin was given concurrently with probenecid (oral, 1 g), in which impaired renal excretion. The combination of amoxicillin with clavulanat can not be recommended. Merupkan cotrimoxazole combination of sulfamethoxazole with trimethoprim (400mg/80mg), oral, 3 days). Thiamphenicol 2.5 g administered orally, for 2 days. Kanamycin given i.m. (2 g, single dose). given gentamicin 240 mg, i.m.

Tetracycline is not recommended to treat gonorrhea, since multiple-dose therapy and is contraindicated in pregnancy and neonates. New Macrolide as azithromycin (oral, 1 g, single dose) are not recommended for gonorrhea, but can be used in some places though they're expensive