Clinical Evidence Concise
A Publication of BMJ Publishing Group
Am Fam Physician. 2005 Jul 1;72(01):129-130.
This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The evidence is available at http://www.clinicalevidence.com/ceweb/conditions/seh/1604/1604.jsp.
What are the effects of treatments for uncomplicated infections in men and nonpregnant women?
Single-dose Antibiotic Regimens (Based on Comparisons of Results Across Arms of Different Trials). One systematic review found limited evidence that single-dose regimens (e.g., ceftriaxone, ciprofloxacin, gatifloxacin, spectinomycin, azithromycin, ofloxacin, and cefixime) achieve cure rates of 95 percent or higher in urogenital or rectal infection. Cure rates were lower (about 80 percent) for pharyngeal infection. Resistance to penicillins, tetracyclines, and sulfonamides is now widespread, and resistance to fluoroquinolones has become common in some geographic areas.
What are the effects of treatments for uncomplicated infections in pregnant women?
Single-dose Antibiotic Regimens. One systematic review found that antibiotic treatment (e.g., amoxicillin plus probenecid, spectinomycin, ceftriaxone, and cefixime) was effective for curing gonorrhea in pregnant women. We found no reports of serious adverse effects.
What are the effects of treatments for disseminated gonococcal infection?
LIKELY TO BE BENEFICIAL
Multidose Antibiotic Regimens (Based on Nonrandomized Controlled Trials Evidence and Consensus). We found no randomized controlled trials (RCTs) assessing treatments for disseminated gonococcal infection, but there is consensus that multidose regimens using injectable cephalosporins or quinolones (except where quinolone-resistant Neisseria gonorrhoeae have been reported) are the most effective treatments. We found no reports of treatment failures with these regimens.
What are the effects of dual treatment for gonorrhea and chlamydia infection?
Dual Antibiotic Treatment. Dual treatment with an antimicrobial effective against gonorrhea and chlamydia infections is based on theory and expert opinion rather than on evidence from RCTs. The balance between benefits and harms will vary with the prevalence of coinfection in each population.
Gonorrhea is caused by N. gonorrhoeae infection. In men, uncomplicated urethritis is the most common manifestation, with dysuria and urethral discharge. Less typically, signs and symptoms are mild and indistinguishable from those of chlamydial urethritis. In women, the most common site of infection is the uterine cervix where infection results in symptoms such as vaginal discharge, lower abdominal discomfort, and dyspareunia in one half of cases. Coinfection with Chlamydia trachomatis is reported in 20 to 40 percent of people.1–3
Between 1975 and 1997, the reported incidence of gonorrhea in the United States fell by 74 percent, reaching a nadir of 122 cases per 100,000 people. Since 1997, 125 to 133 cases have been reported per 100,000 people each year.4 Rates are highest in younger persons. In 2002, the incidence of gonorrhea was highest in women 15 to 19 years of age (676 cases per 100,000 people) and men 20 to 24 years of age (538 cases per 100,000 people). In England, Wales, and Northern Ireland, diagnoses of gonorrhea have increased between 1994 to 2002, reaching 296 cases per 100,000 people for 20- to 24-year-old men and 214 cases per 100,000 people for 16- to 19-year-old women in 2002.5
Most infections result from penile–vaginal, penile–rectal, or penile–pharyngeal contact. An important minority of infections are transmitted from mother to child during birth, which can cause a sight-threatening purulent conjunctivitis (ophthalmia neonatorum). Less common are ocular infections in older children and adults caused by sexual exposure, poor hygiene, or the medicinal use of urine.
The natural history of untreated gonococcal infection is spontaneous resolution and microbiological clearance after weeks or months of unpleasant symptoms.6 During this time, there is a substantial likelihood of transmission to others and of complications developing in the infected individual.6 In many women, the lack of readily discernible signs or symptoms of cervicitis means that infections go unrecognized and untreated. An unknown proportion of untreated infections causes local complications, including lymphangitis; periurethral abscess; bartholinitis; urethral stricture and epididymitis in men; and in women involvement of the uterus, fallopian tubes, or ovaries causing pelvic inflammatory disease. One review found N. gonorrhoeae was cultured from 8 to 32 percent of women with acute pelvic inflammatory disease in 11 European studies and from 27 to 80 percent of women in eight American studies.7 The proportion of N. gonorrhoeae infections in women that lead to pelvic inflammatory disease has not been well studied. However, one study of 26 women exposed to men with gonorrhea found that 19 women were culture positive and of these, five women had pelvic inflammatory disease and another four had uterine adnexal tenderness.8 Pelvic inflammatory disease may lead to infertility. In some people, localized gonococcal infection may disseminate. An American study estimated the risk of dissemination to be 0.6 to 1.1 percent among women, whereas a European study estimated it to be 2.3 to 3.0 percent.9,10 The same European study found a lower risk in men, estimated to be 0.4 to 0.7 percent.10 When gonococci disseminate, they cause petechial or pustular skin lesions; asymmetrical arthropathies, tenosynovitis, or septic arthritis; and rarely, meningitis or endocarditis.
search date: July 2004
Adapted with permission from Moran J. Gonorrhoea. Clin Evid Concise 2004;432–3.
1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep. 2002;51:36–42.
2. Creighton S, Tenant-Flowers M, Taylor CB, et al. Co-infection with gonorrhoea and chlamydia: how much is there and what does it mean? Int J STD AIDS. 2003;14:109–13.
3. Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated forNeisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003;139:178–85.
4. Division of STD Prevention, Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2002. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2003. Accessed online June 6, 2005, at: http://www.cdc.gov/std/stats.
5. Health Protection Agency. Epidemiological Data—Gonorrhoea. Accessed online June 6, 2005, at: http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/stigonorrhoea/epidemiology/epidemiology.htm.
6. Hook EW, Handsfield HH. Gonococcal infections in the adult. In: Holmes KK, Mardh PA, Sparling PF, et al., eds. Sexually transmitted diseases. 3d ed. New York: McGraw-Hill, 1999.
7. Cates WC Jr, Rolfs RT, Aral SG. Sexually transmitted diseases, pelvic inflammatory disease, and infertility: an epidemiologic update. Epidemiol Rev. 1990;12:199–220.
8. Platt R, Rice PA, McCormack WM. Risk of acquiring gonorrhoea and prevalence of abnormal adnexal findings among women recently exposed to gonorrhoea. JAMA. 1983;250:3205–9.
9. Holmes KK, Wiesner PJ, Pedersen AH. The gonococcal arthritis-dermatitis syndrome. Ann Intern Med. 1971;75:470–1.
10. Barr J, Danielsson D. Septic gonococcal dermatitis. BMJ. 1971;1:482–5.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Klara Brunnhuber (email@example.com). This series is part of the AFP’s CME. See “Clinical Quiz” on page 27.
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