Board Exam Corner

Treating gonococcal infections


 

Editor’s Note: This is the third installment of a six-part monthly series that will review key concepts and articles that ob.gyns. can use to prepare for the American Board of Obstetrics and Gynecology Maintenance of Certification examination. The series is adapted from Ob/Gyn Board Master (obgynboardmaster.com), an online board review course created by Erudyte Inc. The series will cover issues in reproductive endocrinology and infertility, maternal-fetal medicine, gynecologic oncology, and female pelvic medicine, as well as general test-taking and study tips.

Management of sexually transmitted infections will always be tested on any ob.gyn. examination. Since the American College of Obstetricians and Gynecologists issued two new committee opinions in 2015 focusing on the dual treatment for gonococcal infections and expedited partner therapy in the management of gonorrhea and chlamydial infection, it is wise to review this topic.1,2

Dr. Sam Siddighi

Dr. Sam Siddighi

Let’s begin with a possible medical board question: What is the best treatment for N. gonorrhoeae infection during pregnancy for a patient with severe cephalosporin allergy?

A. Ciprofloxacin

B. Ciprofloxacin plus azithromycin

C. Cefixime plus azithromycin

D. Doxycycline plus azithromycin

E. Gentamicin plus azithromycin

The correct answer is E.

Dual therapy with gentamicin (240 mg single-intramuscular dose) and azithromycin (2 grams single-oral dose) is the treatment of choice for pregnant patients with severe penicillin or cephalosporin allergy. Gentamicin is safe during pregnancy. An alternative regimen is a single dose of azithromycin, if the patient is allergic to gentamicin and cephalosporin. For this patient, the physician needs to perform a test-of-cure 1 week after treatment.

Answer A is incorrect because neither doxycycline nor quinolones are recommended during pregnancy.

Answer B and C are incorrect because the patient is allergic to cephalosporin (ceftriaxone and cefixime).

Answer D in incorrect because neither doxycycline nor quinolones are recommended during pregnancy.

Key points

The key points to remember are:

  • Ceftriaxone and azithromycin must be started on the same day.
  • In patients with HIV, the treatment is same: Ceftriaxone 250-mg single-intramuscular dose plus azithromycin 1-g single-oral dose.
  • The Centers for Disease Control and Prevention and state health departments will periodically update the most current information on gonococcal susceptibility.
  • Despite nucleic acid amplification test (NAAT) being negative for Chlamydia trachomatis, dual treatment with a cephalosporin plus either azithromycin or doxycycline is recommended by ACOG to prevent resistance to cephalosporins.
  • ACOG does not recommend test-of-cure after treatment of uncomplicated gonorrhea.
  • ACOG does not recommend test-of-cure after treatment of pregnant patients.
  • ACOG recommends test-of-cure for pharyngeal gonorrhea only if the patient received an alternative regimen treatment after 14 days.
  • ACOG accepts both culture or NAAT as a test-of-cure.
  • Cefixime is not a first-line regimen treatment for gonorrhea and dual therapy with ceftriaxone and azithromycin is the only recommended first-line regimen.

Literature summary

The guidelines from the ACOG Committee on Gynecologic Practice outline recommended antibiotic treatment regimens, considerations when treating special populations, and advice for expedited therapy for sexual partners.

  • The first-line regimen is ceftriaxone 250-mg, single-intramuscular dose plus azithromycin 1-g, single-oral dose.
  • The second-line regimen takes into account allergies and shortages. In the case of a severe penicillin allergy, use gemifloxacin 320-mg, single-oral dose plus azithromycin 2-g, single-oral dose. Another option is gentamicin, 240-mg, single-intramuscular dose plus azithromycin 2-g, single-oral dose. When ceftriaxone is not available, ACOG recommends cefixime, 400-mg, single-oral dose plus azithromycin 1-g, single-oral dose.
  • In pregnancy, ACOG recommends the same treatment, with no need for test-of-cure if treated properly. For severe penicillin or cephalosporin allergy in pregnancy, use gentamicin 240-mg, single-intramuscular dose plus azithromycin 2-g, single-oral dose. For allergy to gentamicin and cephalosporins, use azithromycin 2-g single-oral dose and send a test-of-cure in 1 week. Do not use doxycycline or quinolones during pregnancy.
  • In HIV infection, use the general recommended treatment regimen and there is no need for a test-of-cure if treated properly.
  • For sex partners, ACOG recommends evaluation and treatment for partners in the last 60 days. They should abstain from sex for 7 days after treatment. Expedited partner therapy with cefixime and azithromycin is recommended, but review the legal the status of expedited partner therapy in your state before prescribing.

References

1. Obstet Gynecol. 2015 Nov;126(5):e95-9.

2. Obstet Gynecol. 2015 Jun;125(6):1526-8.

Dr. Siddighi is editor-in-chief of the Ob/Gyn Board Master and director of female pelvic medicine and reconstructive surgery and director of grand rounds at Loma Linda University Health in California. Ob.Gyn. News and Ob/Gyn Board Master are owned by the same parent company, Frontline Medical Communications.

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