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Gonorrhea and Chlamydia
Guide for HIV/AIDS Clinical Care, HRSA HIV/AIDS Bureau
Gonorrhea, caused by Neisseria gonorrhoeae (GC), and chlamydia, caused by Chlamydia trachomatis (CT), are sexually transmitted diseases (STDs). These infections may be transmitted during oral, vaginal, or anal sex; they also can be transmitted from a mother to her baby during delivery and cause significant illness in the infant.
Both organisms can infect the urethra, oropharynx, and rectum in women and men; the epididymis in men; and the cervix, uterus, and fallopian tubes in women. Untreated GC or CT infection in women may lead to pelvic inflammatory disease (PID), which can cause chronic pelvic pain and scarring of the fallopian tubes that results in infertility or ectopic pregnancy (tubal pregnancy). N. gonorrhoeae can cause disseminated infection involving the skin, joints, and other systems. Infection with GC or CT may facilitate transmission of HIV to HIV-uninfected sex partners.
Certain strains of CT can cause lymphogranuloma venereum (LGV). This infection is common in parts of Africa, India, Southeast Asia, and the Caribbean. While relatively uncommon in the United States, outbreaks among men who have sex with men (MSM) have been reported in recent years. LGV may cause genital ulcers, followed by inguinal adenopathy; it also can cause proctocolitis with anorectal discharge, tenesmus, and pain.
Patients with symptoms of gonorrhea or chlamydia should be evaluated and treated as indicated below. Although GC or CT urethral infections in men may cause symptoms, infection in women and oral or rectal infections in men often cause no symptoms. Thus, sexually active individuals at risk of GC and CT exposure should receive regular screening for these infections as well as for syphilis and other STDs; for most patients, this should be at least annually, and every 3-6 months for persons at higher risk (see chapter Initial and Interim Laboratory and Other Tests).
Symptoms will depend on the site of infection (e.g., oropharynx, urethra, cervix, rectum). Symptoms are not present in many patients, thus it is important to screen all patients at risk of STDs.
If symptoms are present, women may notice the following (depending on site of infection):
If symptoms are present, men may notice the following (depending on site of infection):
During the history, ask the patient about the following:
During the physical examination, check for fever and document other vital signs.
For women, focus the physical examination on the mouth, abdomen, and pelvis. Inspect the oropharynx for discharge and lesions; check the abdomen for bowel sounds, distention, rebound, guarding, masses, and suprapubic or costovertebral angle tenderness; perform a complete genital and vaginal examination for abnormal discharge or bleeding; check for uterine, adnexal, or cervical motion tenderness; and search for pelvic masses or adnexal enlargement. Check the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. Check the skin for rashes and lesions.
For men, focus the physical examination on the mouth, genitals, and anus/rectum. Check the oropharynx for lesions, the urethra for discharge, the external genitalia for tenderness, masses, or lesions, and the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy. Check the skin for rashes and lesions.
A partial differential diagnosis includes the following:
Test for oral, urethral, or anorectal infection, according to symptoms and anatomic site(s) of possible exposures. Perform testing for both gonorrhea and chlamydia (testing for pharyngeal CT infection generally is not recommended although the CT pharyngeal test often accompanies the GC pharyngeal nucleic acid amplification test [NAAT]). The availability of the various testing methods varies according to the specific clinic site. Consider the following:
Treatments for gonorrhea and chlamydia are indicated below. Fluoroquinolone-resistant GC is widespread in the United States and worldwide. Thus, the U.S. Centers for Disease Control and Prevention (CDC) recommends that fluoroquinolones not be used for treatment of GC. Similarly, resistance of GC to cephalosporins is emerging, though third-generation cephalosporins are effective against most GC strains in the United States and remain the only recommended treatment for GC. GC strains with decreased susceptibility to azithromycin also have been reported, and azithromycin should be used to treat GC only for select patients in whom treatment with a cephalosporin should be avoided.
Adherence is essential for treatment success. Single-dose treatments maximize the likelihood of adherence and are preferred. Other considerations in choosing the treatment include antibiotic resistance, cost, allergies, and pregnancy. For further information, see the CDC STD treatment guidelines (see "References," below); treatments should be given in accordance with these guidelines.
Any sex partners within the past 60 days, or the most recent sex partner from >60 days before diagnosis, also should receive treatment. Patients should abstain from sexual activity for 7 days after a single-dose treatment or until a 7-day treatment course is completed. Reinfection with GC or CT is likely if reexposure occurs; patients with either GC or CT should be rescreened 3 months after treatment.
Treatment options include the following (see the full CDC STD treatment guidelines, referenced below); the current guidelines emphasize that dual therapy for GC should be given, with ceftriaxone plus either azithromycin or doxycycline. Ceftriaxone is the recommended cephalosporin for GC infection at any anatomic site. Coadministration of azithromycin or doxycycline is intended to improve the likelihood of cure and may decrease the risk of emergent cephalosporin resistance; it should be given, even if testing for CT is negative.
* If an alternative regimen is used, a test of cure (TOC) should be done in 1 week: GC culture (preferred) or NAAT. A positive NAAT result should be followed by confirmatory culture and antimicrobial susceptibility testing. Possible cephalosporin treatment failures should be reported immediately to the local or state health department.
Note: Fluoroquinolones are not recommended for treatment of gonococcal infection because of widespread resistance in the United States.
Please see full CDC STD treatment guidelines regarding treatment of PID, epididymitis, and disseminated gonococcal infection.
(See the full CDC STD treatment guidelines, referenced below.)
For recent sex partners (within 60 days before the onset of patient's symptoms), test for urethral or cervical CT, treat with azithromycin 1 g PO in a single dose or doxycycline 100 mg PO BID for 7 days.
Use of fluoroquinolones and tetracyclines should be avoided during pregnancy.
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