Gonorrhea - Uncomplicated Anogenital Infection Follow Up

Monitoring is helpful to confirm patient compliance with the treatment; ensure resolution of symptoms; inquire about the possibility of re-infection, adverse reaction to treatment, or treatment failure and drug resistance; and check on partner notification.

A routine test of cure is recommended in the following individuals: Those with persistent signs and symptoms; those with pharyngeal infection; in whom antimicrobial susceptibility is not known; those treated with agents other than Ceftriaxone; and those who are pregnant. Some authorities have recommended that a test of cure should be done in all patients with gonococcal infection, giving priority to those with persistent signs or symptoms after the treatment and those patients treated with an alternative regimen with unknown antimicrobial susceptibility. A test of cure should be done 1-2 weeks after completion of treatment. Others have recommended a test of cure to be done 72 hours after completion of therapy in patients with persistent signs and symptoms or 2 weeks after in asymptomatic patients. Ideally performed with culture or, if not available, with nucleic acid amplification test (NAAT) 2 weeks after treatment for Neisseria gonorrhoeae. Confirmatory culture should be done if NAAT’s result is positive. If the culture is positive, phenotypic antimicrobial susceptibility testing should be performed.

Pregnant women should be retested 3 months after therapy and during the third trimester if risk for gonococcal infection is high. Infections identified after treatment typically are due to reinfection, which should be distinguished from treatment failure prior to retreatment. The WHO advises that in cases of suspected reinfection, patients should be retreated with a WHO-recommended regimen while emphasizing sexual abstinence, consistent condom use, and partner treatment. Reinfected patients are retreated with the recommended regimen, sexual abstinence or condom use is reinforced, and their partners are treated. There may be a need for improved patient education and referral of sex partners.

Due to the emerging resistance to extended-spectrum cephalosporins in Neisseria gonorrhoeae, criteria for probable gonorrhea treatment failure include the following: A patient with a laboratory-confirmed N gonorrhoeae infection treated with cephalosporin-based regimen and subsequently tested positive for N gonorrhoeae (culture positive ≥72 hours after treatment or NAAT positive ≥7 days after treatment) and without sexual activity following treatment, and pre- or post-treatment antimicrobial susceptibility testing of N gonorrhoeae isolates showed Ceftriaxone MIC ≥0.125 mcg/mL or Cefixime MIC ≥0.25 mcg/mL.

If treatment failure follows a regimen not recommended by WHO, the organization advises retreatment using a WHO-recommended therapy. If treatment failure occurs after a WHO-recommended regimen and reinfection is considered unlikely, the WHO advises retreating with a previously unused option from the recommended alternatives and performing a test of cure. Alternative regimens include a combination of Azithromycin with either Ceftriaxone (if not used earlier), Spectinomycin or Gentamicin. If treatment failure happens after single therapy, re-treat with dual therapy. If treatment failure happened after dual therapy, re-treat with a dual therapy of a higher dose. Culture of relevant specimens and susceptibility testing of N gonorrhoeae should be done in patients who have failed with the recommended treatment regimen, and re-treat according to susceptibility results. If treatment fails and antimicrobial susceptibility data are available, WHO recommends selecting retreatment based on the organism’s susceptibility profile. Retreatment should occur promptly, and if the individual still does not respond, they should be referred to a specialist for further evaluation and management. Patients who had treatment failure with alternative regimens should be treated with Ceftriaxone and Azithromycin and be referred to an infectious disease specialist for further management.