[Table of Contents]

Canadian STD Guidelines

Gonococcal Infections

Treatment

ALL PATIENTS TREATED FOR GONORRHEA SHOULD ALSO BE TREATED FOR CHLAMYDIAL INFECTION

ADOLESCENTS AND ADULTS (except pregnant women and nursing mothers)(a)

Urethral, endocervical, rectal, pharyngeal infection
(pelvic inflammatory disease)
(epididymitis)

All regimens followed by doxycycline/tetracycline/azithromycin*

Preferred (IM):


• ceftriaxone 125 mg IM in a single dose

Preferred (oral) (alphabetical order):


• cefixime 400 mg orally in a single dose
  or
  
• ciprofloxacin** 500 mg orally in a single dose
  or
  
• ofloxacin** 400 mg orally in a single dose

Alternative (IM): except pharyngeal

• spectinomycin 2 g IM in a single dose
  PLUS
  doxycycline/tetracycline/azithromycin

* Azithromycin 1 g orally in a single dose is an alternative for the empiric treatment of chlamydia. There are only limited data, as yet, to support the use of azithromycin in non- gonococcal/non-chlamydial urethritis or cervicitis; more studies are currently being carried out.

** Ciprofloxacin and ofloxacin should not be used if there is a possibility that the infection was acquired in Southeast Asia. If either ciprofloxacin or ofloxacin is used in such a case, a test-of-cure is recommended.

PREGNANT WOMEN AND NURSING MOTHERS

Urethral, endocervical, rectal or pharyngeal infection

• the treatment regimens for adults and adolescents should be followed except that ofloxacin and ciprofloxacin are contraindicated and doxycycline/tetracycline should be replaced by erythromycin 2 g/day in divided doses for at least 7 days OR if not tolerated erythromycin 1 g/day in divided doses for 14 days may be substituted (erythromycin estolate is contraindicated in pregnancy). Amoxicillin 3 g orally or ampicillin 3.5 g orally with probenicid 1 g orally can be considered if isolate is known to be sensitive.

Gonococcal ophthalmia (adolescent and adult)
Disseminated infection: arthritis, meningitis

Preferred initial therapy:

• ceftriaxone 2 g/day IM
  PLUS doxycycline/tetracycline/azithromycin
  while awaiting consultation

CHILDREN UNDER 9 YEARS(a,b)

Urethral, vaginal, rectal, pharyngeal infection

• cefixime 16 mg/kg orally in a single dose (max 400 mg)(b)
  PLUS erythromycin
  OR
  
• ceftriaxone 125 mg IM in a single dose
  PLUS erythromycin

Alternative: except pharyngeal

• spectinomycin 40 mg/kg IM (max 2 g) in a single dose
  PLUS erythromycin

NOTE:
erythromycin 40 mg/kg/day orally in divided doses (max 500 mg x 4/day) for 7 days as treatment for chlamydial infection, which should always be included

Disseminated infection: arthritis, meningitis, gonococcal ophthalmia beyond
neonatal period

Preferred initial therapy:

• ceftriaxone 50-100 mg/kg/day IM or IV
  PLUS erythromycin
  while awaiting consultation

NEONATAL INFECTION(b)

Ophthalmia neonatorum

• culture eye discharge, blood (CSF only if evidence of systemic disease)
  
• irrigate eyes immediately with sterile normal saline and at least hourly as long as necessary to eliminate discharge
  
• start ceftriaxone 50-100 mg/kg/day IV or IM (single dose therapy may be adequate if blood culture is negative)
  
• consult with a specialist as soon as possible

Newborns born to women infected with gonorrhea

• ceftriaxone 125 mg IM in a single dose PLUS erythromycin in the following dosage schedule

if < 7days of age and < 2000 g

• erythromycin 20 mg/kg/day orally in divided doses

  if < 7 days of age and > 2000 g
  

• erythromycin 30 mg/kg/day orally in divided doses

  if > 7 days of age
  

• erythromycin 40 mg/kg/day orally in divided doses

  
  

1. ceftriaxone and cefixime should not be given to persons with cephalosporin allergy or a history of immediate and/or anaphylactic reactions to penicillins
   

2. oral therapies are preferred in children. Recommendations for the use of cefixime are based on data showing efficacy in the treatment of infections caused by organisms similar to Neisseria gonorrhoeae. Because there is limited experience with the use of cefixime in children with gonococcal infections, antimicrobial susceptibility must be ascertained AND follow-up culture assured. If follow-up cannot be assured, use ceftriaxone 125 mg IM in place of cefixime.

Other points

• the preferred diluent for IM ceftriaxone is 1% lidocaine without epinephrine (0.9 mL/250 mg, 0.45 mL/125 mg) to reduce discomfort
  
• in adults, if tetracyclines are contraindicated or not tolerated, use erythromycin 2 g/day orally in divided doses for 7 days (1 g/day in divided doses for 14 days if higher dose not tolerated). Other formulations of erythromycin can be substituted in appropriate doses except that erythromycin estolate is contraindicated during pregnancy.
  
• erythromycin dosages refer to erythromycin base. Equivalent dosages of other formulations may be substituted.

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