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Gonorrhoea

Queensland Health Guidelines for Public Health Units

Revision History

 Version Date Changes
 2.0January 2015 Full revision of guideline. 
 3.0August 2018Full revision of guideline.

Infectious Agent

The infectious agent is Neisseria gonorrhoeae. A gram-negative intracellular diplococcal bacterium.

Notification and Reporting Criteria

Laboratory notification only. Laboratory reporting to Notifiable Conditions System.

For case definitions see Queensland Notification Criteria: Guidelines for Laboratories.

Public Health Significance and Occurrence

Gonorrhoea notifications have increased in all states and territories. Gonorrhoea has increased in heterosexual women and men, as well as in men who have sex with men. There have been two cases of multi-drug resistant (MDR) gonorrhoea detected in Australia that are highly resistant to all of the antibiotics that have been in routine use to treat gonorrhoea. 

Gonorrhoea is a sexually transmissible bacterial disease that is common worldwide and affects both genders. In Australia it is most commonly diagnosed in men who have sex with men (MSM), among young heterosexual Aboriginal and Torres Strait Islander people living in remote and very remote areas, and in travellers returning from high prevalence areas overseas. Anogenital infection with N. gonorrhoeae increases the risk of acquiring and transmitting HIV infection. Co-infection with other sexually transmissible infections (STIs) is common.

The prevalence of antibiotic resistance to penicillin, tetracyclines, macrolides and more recently fluroquinolones is widespread and increasing. There are currently substantial geographic differences in decreased susceptibility patterns in Australia and dual therapy has been recommended as a strategy to address development of more widespread resistance. In particular, treatment failures have been reported for pharyngeal infections and multi-drug resistance for extra-genital sites. It can be challenging to distinguish between re-infection and treatment failure unless a nucleic acid amplification testing (NAAT) test of cure is performed two weeks after treatment. It is important to be aware that NAAT does not allow for antimicrobial resistance testing and, wherever possible, specimens for culture should also be collected.

Male urethral infection is usually symptomatic but infection of the cervix, anus and pharynx is often asymptomatic. Women with gonorrhoea may experience vaginal or anal discharge or pelvic pain if symptomatic. Conjunctivitis occurs in neonates and less commonly in adults, and may cause blindness if not treated promptly. Dissemination of infection may uncommonly result in gonococcal septicaemia, arthritis, endocarditis and meningitis.

Possible sequelae of gonococcal infection in men include epididymitis and prostatitis. Epididymo-orchitis could potentially impair fertility. In women, infection can result in endometritis, salpingitis and pelvic inflammatory disease (PID); with further sequelae of chronic pelvic pain, sub-fertility and ectopic pregnancy.

Infection during pregnancy can result in premature rupture of membranes and premature delivery, with attendant morbidity and mortality. N.gonorrhoeae can be transmitted to the neonate, usually at delivery, resulting in ocular and/or anogenital infection. A high proportion of the children born to an infected mother are infected during birth.

Differentiating infection acquired at birth from infection related to sexual abuse may be difficult in very young children. To determine whether there may be sexual transmission and hence the possibility of sexual abuse, consultation with sexual health, pediatric, and/or child safety staff may be necessary. Refer to the reporting a reasonable/ reportable suspicion of child abuse and neglect guideline.

Resources, including contact lists and fact sheets for Queensland Health staff are also available via the Queensland Health intranet.  Search for ‘child protection’.

Clinical Features

See Australian STI Management Guidelines and/or Primary Clinical Care Manual . A doctor’s fact sheet and patient handout are available in the Australasian Contact Tracing Manual

Mode of Transmission

Sexual partners exposed by vaginal, oral or anal sex, without using a condom or dam, are at high risk of infection.

Investigation and Screening

See Australian STI Management Guidelines and/or Primary Clinical Care Manual.

Whenever possible, take swabs for culture and antimicrobial resistance testing, particularly for those people with a travel history to south-east Asia. Take microculture and NAAT specimens from all potentially infected sites – 1 or more of oropharyngeal, genital, anal.

NAATs are highly sensitive and allow for self-collected specimens. A gonococcal culture swab allows for antibiotic susceptibility testing but is not as sensitive as NAAT. Culture accuracy depends on good swab management and transport condition.

For screening of asymptomatic individuals see Guidelines for Preventive Activities in General Practice, for screening of at risk groups see 'Populations and Situations' in the Australian STI Management Guidelines.

Period of Communicability

May extend for months in untreated individuals. Effective treatment ends communicability within hours.

Management

Cases

All persons diagnosed with gonorrhoea should be tested for other STIs, including chlamydia, syphilis, and HIV. See Australian STI Management Guidelines and/or Primary Clinical Care Manual.

  • Treat gonorrhoea with both ceftriaxone 500 mg IM AND azithromycin 1 g orally.
  • Review in one week to assess symptom resolution (if appropriate) and confirm partner notification.
  • Advise all cases to have no sexual contact for 7 days after treatment is administered
  • Advise no sex with partners from the last 2 months until the partners have been tested and treated
  • Undertake test of cure 2 weeks after treatment using NAAT (PCR).
  • Seek expert advice from your local sexual health service about patients with treatment failure or allergy to cephalosporins.
  • Test for re-infection after 3 months (if appropriate)

Contacts

Contact tracing for gonorrhoea is a high priority and should be performed in all patients with confirmed infection. Contact tracing can be conducted by the index case, the treating service provider, a referral agency (following consent by the index case), or a combination of these. For further information see contact tracing for sexually transmissible infections.

Male and female partners should be traced back for a minimum of two months. All contacts must be treated as well as tested. See Australian STI Management Guidelines and/or Primary Clinical Care Manual.

Preventive Measures

General promotion of safer sex practices, including the consistent use of condoms or dams with all sexual partners and for oral sex. Provision of education and counselling regarding STIs and negotiating safer sex.

Avoidance of any sexual contact when anogenital symptoms are present or for seven days after treatment has been administered for a confirmed infection.

Contact Details of Queensland Health Sexual Health Services

References

Australasian Society for HIV Medicine, 2016. Australasian Contact Tracing Guidelines

Australasian Society for HIV Medicine, March 2018. Australian STI Management Guidelines for use in Primary Care

Australian Gonococcal Surveillance Programme Annual Report, 2015

Royal Australian College of General Practitioners, Guidelines for preventative activities in general practice, 9th edition.

The State of Queensland (Queensland Health) and the Royal Flying Doctor Service (Queensland Section), 2016. Primary Clinical Care Manual, 9th edition.

Australian Government Department of Health. 17 April 2018. Multi-drug resistant gonorrhoea

Whiley DM, Jennison A, Pearson J, Lahra MM. July 2018. Genetic characterisation of Neisseria gonorrhoeae resistant to both ceftriaxone and azithromycin

Last updated: 3 August 2018