Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 6: Disease-Specific Treatment

Gonorrhea and Chlamydia

Background

Gonorrhea, caused by Neisseria gonorrhoeae (GC), and chlamydia, caused by Chlamydia trachomatis (CT), are sexually transmitted infections (STIs). These infections may be transmitted during oral, vaginal, or anal sex; they can also be transmitted from the mother to 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 in women may lead to pelvic inflammatory disease, which can cause scarring of the fallopian tubes and result in infertility or ectopic pregnancy (tubal pregnancy). The organisms can also affect other sites; N gonorrhoeae can cause disseminated infection involving the skin, joints, and other systems.

Certain strains of CT can cause lymphogranuloma venereum (LGV). This infection is common in parts of Africa, India, Southeast Asia, and the Caribbean. Outbreaks among men who have sex with men (MSM) have been reported over the past several years in Europe and the United States. LGV may cause genital ulcers followed by inguinal adenopathy; it can also (as in the recent cases in MSM) cause gastrointestinal symptoms, notably anorectal discharge and pain.

Patients with symptoms of gonorrhea or chlamydia should be evaluated and treated as indicated below. Although GC or CT urethritis in men typically causes symptoms, urethral infection in women and oral or rectal infections in both men and women often cause no symptoms. In fact, a substantial number of individuals with GC or CT infection have no symptoms. Thus, sexually active individuals at risk for GC and CT should receive regular screening for these infections as well as for syphilis and other STIs. Patients are frequently infected with both N gonorrhoeae and C trachomatis, so they should be tested and treated for both.

S: Subjective

Symptoms will depend on the site of infection (eg, oropharynx, urethra, cervix, rectum). Symptoms are not present in all patients.

If symptoms are present, women may notice:

• Vaginal discharge
• Urinary hesitancy
• Pain with sexual intercourse
• Pain or burning on urination
• Abdominal or pelvic pain
• Sore throat
• Mouth sores
• Rectal discharge
• Anal discomfort

If symptoms are present, men may notice:

• Increased urinary frequency or urgency
• Urethral discharge
• Red or swollen urethra
• Incontinence
• Pain on urination
• Testicular tenderness or pain
• Rectal discharge
• Anal discomfort

During the history, ask the patient about the following:

• Any of the symptoms listed above, and their duration
• Previous diagnosis of gonorrhea or chlamydia
• New sex partner(s)
• Unprotected sex (oral, vaginal, anal)
• Use of an intrauterine device
• Last menstrual period, and whether the patient could be pregnant

O: Objective

Physical Examination

During the physical examination, check for fever and document other vital signs.

In 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 pelvic 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.

In men, focus the physical examination on the mouth, genitals, and anus/rectum. Check the oropharynx for discharge and lesions, the urethra for discharge, the external genitalia for other lesions, and the anus for discharge and lesions; perform anoscopy if symptoms of proctitis are present. Check for inguinal lymphadenopathy.

A: Assessment

A partial differential diagnosis includes the following:

• Urinary tract infection
• Dysmenorrhea
• Appendicitis
• Cystitis
• Proctitis
• Pelvic inflammatory disease (PID)
• Irritable bowel syndrome
• Pyelonephritis

P: Plan

Diagnostic Evaluation

Test for oral, urethral, or anorectal infection, according to symptoms and possible exposures. Perform concurrent testing for both gonorrhea and chlamydia. The availability of the various testing methods depends on the clinical site. Consider the following:

• Gram stain (pharyngeal, cervical, or urethral discharge)
• Culture (oropharynx, endocervix, urethra, rectum)
• Nucleic acid amplification test (NAAT): urine specimens (first stream) and urethral, vaginal, and endocervical swab specimens; has also been used for pharyngeal and rectal swab specimens, although it is not currently approved for this use
• Nucleic acid hybridization assay (DNA probe): endocervical and male urethral swab specimens
• Serologic tests (microimmunofluorescence test or complement fixation test) for suspected LGV

Treatment

Treatments for gonorrhea and chlamydia are indicated below. High rates of fluoroquinolone-resistant N gonorrhoeae exist in California, Hawaii and the Pacific Islands, Asia, and Great Britain. Fluoroquinolone-resistant GC is also common among MSM in the United States. Thus, the U.S. Centers for Disease Control and Prevention (CDC) recommends that fluoroquinolones not be used for treatment of GC in MSM or in any patient infected in the areas listed above, unless antimicrobial susceptibility test results are used to guide therapy.

Because dual infection is common, patients diagnosed with either GC or CT should receive empiric treatment for both infections, unless the other infection has been ruled out. Reinfection is likely if reexposure occurs. Any sex partners within the last 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.

Adherence is essential for treatment success. Single-dose treatments maximize the likeliness 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 and the revised recommendations (references below).

Treatment of Gonorrhea

Treatment options include the following. (See the full CDC STD treatment guidelines, referenced below.)

• Ceftriaxone 125 mg or 250 mg intramuscular (IM) injection in a single dose (some providers recommend 250 mg because of slightly higher cure rates)
• Cefixime 400 mg orally in a single dose (tablet formulation not currently available in the United States)
• Spectinomycin 2 g IM injection in a single dose (for urogenital or anorectal GC; not sufficiently effective to treat pharyngeal GC)
• Cefpodoxime 400 mg orally in a single dose (insufficient data to be recommended by the CDC)
• Ciprofloxacin 500 mg orally in a single dose (see "Note" below)
• Ofloxacin 400 mg orally in a single dose (see "Note" below)
• Levofloxacin 250 mg orally in a single dose (see "Note" below)
• Azithromycin 2 g orally in a single dose (not recommended by the CDC; high rate of gastrointestinal intolerance)

Note: Fluoroquinolones are not recommended for treatment of gonococcal infection in MSM or in any patient who acquired GC infection in California, Hawaii, Massachusetts, New York City, the Pacific Basin, Asia, or Great Britain, because of the high prevalence of fluoroquinolone resistance.

Treatment of Chlamydia

(See the full CDC STD treatment guidelines, referenced below.)

Recommended regimens

• Azithromycin 1 g orally in a single dose
• Doxycycline 100 mg orally twice daily for 7 days

Alternative regimens

• Erythromycin base 500 mg orally 4 times daily for 7 days
• Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days
• Ofloxacin 300 mg orally twice daily for 7 days (see note above)
• Levofloxacin 500 mg orally once daily for 7 days (see note above)

Treatment of LGV

Recommended regimens

• Doxycycline 100 mg orally twice daily for 21 days

Alternative regimens

• Erythromycin base 500 mg orally 4 times daily for 21 days
• Azithromycin 1 g orally once a week for 3 weeks (limited data)

For recent sex partners (within 30 days of the onset of symptoms), treat with azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days.

Treatment during Pregnancy

Fluoroquinolones and tetracyclines should be avoided during pregnancy. For the treatment of GC in pregnant women, the CDC advises using either a recommended cephalosporin or spectinomycin. For the treatment of CT in pregnant women, see the following.

Recommended CT regimens

• Erythromycin base 500 mg orally 4 times daily for 7 days
• Amoxicillin 500 mg orally 3 times daily for 7 days

Alternative CT regimens

• Erythromycin base 250 mg orally 4 times daily for 14 days
• Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days
• Erythromycin ethylsuccinate 400 mg orally 4 times daily for 14 days
• Azithromycin 1 g orally in a single dose

Follow-up

• Evaluate sex partners and treat them if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms.
• Most recurrent infections come from sex partners who were not treated.
• If symptoms persist, evaluate for the possibility of reinfection, treatment failure, or a different cause of symptoms. If treatment failure is suspected, perform culture and antimicrobial sensitivity testing.
• For pregnant women with chlamydia, retest (by culture) 3 weeks after completion of treatment.
• Screen for chlamydia, syphilis, and other STIs at regular intervals according to the patient's risk factors. The sites of sampling (eg, pharynx, urethra, endocervix, anus/rectum) will depend on the patient's sexual exposures.
• Evaluate each patient's sexual practices with regard to the risk of acquiring STIs and of transmitting HIV; work with the patient to reduce sexual risks.

Patient Education

• Instruct patients to take all of their medications. Advise patients to take medications with food if they are nauseated, and to call or return to clinic right away if they have vomiting or are unable to take their medications.
• Sex partners from the previous 60 days need to be tested for sexually transmitted pathogens, and treated as soon as possible with a regimen effective against gonorrhea and chlamydia, even if they have no symptoms. Advise patients to inform their partner(s) that they need to be tested and treated. Otherwise, patients may be reinfected.
• Advise patients to avoid sexual contact until the infection has been cured (at least 7 days).
• Provide education about sexual risk reduction. Instruct patients to use condoms with every sexual contact to prevent reinfection with gonorrhea or chlamydia, to prevent other STIs, and to prevent transmission of HIV to sexual partners.

References

• Abularach S, Anderson J. Gynecologic Problems. In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005. Available online at hab.hrsa.gov/publications/womencare05/.
• Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002 May 10;51(RR-6):1-78.
• Centers for Disease Control and Prevention. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae among men who have sex with men--United States, 2003, and revised recommendations for gonorrhea treatment, 2004. MMWR Morb Mortal Wkly Rep. 2004 Apr 30;53(16):335-8.
• Centers for Disease Control and Prevention. Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. Morb Mortal Wkly Rep. 2004 Oct 29;53(42):985-8.
• Centers for Disease Control and Prevention. Gonorrhea--CDC Fact Sheet Accessed February 7, 2006. Available online at www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm.
• Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women. In: The Medical Clinics of North America, Vol. 87; 2003:971-995.
• Minkoff HL, DeHovitz JA. Care of women infected with the human immunodeficiency virus. JAMA. 1991 Oct 23-30;266(16):2253-8.
• Minkoff HL, DeHovitz JA. HIV infection in women. AIDS Clin Care. 1991; 3: 33-5.
• Moran J. Gonorrhoea. Clin Evid. 2005 Jun;(13):2016-23.