Gonorrhea and Chlamydia
/We talked about most STIs in a series back at the beginning of 2019! This podcast is an update to the treatment guidelines and will replace our last episode on gonorrhea and chlamydia, as these two bugs had some changes in treatment with the 2021 CDC STI guidelines.
First of all, why are we doing these two STDs together?
Because they have a lot of common symptomatology
They may come together (ie. if you have one, you may have the other)
We usually order the two tests together (say it in one breath anyway in the clinic or the ED)
What are gonorrhea and chlamydia and why do we care?
Both are sexually transmitted infections that anyone can get if they are sexually active (any kind of sex), and there is vertical transmission between mother and child
Gonorrhea
Caused by bacteria Neisseria gonorrhoeae (gram negative diplococci)
1.6 million new infections annually in the US
More than 50% occur in patients aged 15-24
Usually symptomless but in men can cause burning with urination, penile discharge, or even testicular pain
In women, 50% are symptomless but can lead to burning with urination, vaginal discharge, intermenstrual bleeding/postcoital spotting, pelvic pain
Can also affect other areas like throat or anus
If untreated, it can lead to pelvic inflammatory disease and infertility. Additionally, at risk for disseminated gonococcal infection
Skin pustules/petechiae, septic arthritis, meningitis, endocarditis
Very rare (0.6-3% of infected women and 0.4-0.7% of infected men
In pregnant patients: septic abortion, chorio, neonatal blindness
Chlamydia
Caused by bacteria Chlamydia trachomatis (gram negative bacteria that only replicates in host cells).
4 million new infections annually in the US
More than 65% occur in patients aged 15-24
Some estimates show at any given time, 1 in 20 sexually active women aged 15-24 has active chlamydia infection in the US.
Again, usually symptomless (70-80%), but can cause vaginal discharge and burning with urination in women
In men, can have discharge from penis, burning with urination, pain and swelling in testicles.
Rectal, oral/throat infections are also possible.
If untreated, can also cause PID and infertility in women → around 15% of women will develop.
Also can cause chlamydia conjunctivitis or trachoma → blindness
Reactive arthritis → can’t see, can’t pee, can’t climb a tree = arthritis, conjunctivitis, urethral inflammation
How do we diagnose them?
Usually a urine test, but can also do endocervical swab, vaginal swab, rectal swab, or pharyngeal swab
Nucleic acid amplification test = gold standard
Who should be tested?
CDC recommends screening:
Of anyone with concern for symptoms;
Annually for GC/chlamydia for all sexually active women younger than 25 years
Opportunistic screening for older women with identified risk factors (ie. new or multiple sexual partners or sex partner who recently had an STI)
For men: once a year for GC/chlamydia for all sexually active MSM, and more frequently (q3-6 months) for MSM who have HIV or if they have multiple or anonymous partners
How do we treat gonorrhea and chlamydia? - note, this is only for adolescents and adults
Treating gonorrhea (NOT disseminated)
Gonorrhea is becoming more and more resistant to antibiotics, and we are down to one class of antibiotic that really treats it: cephalosporins
CDC recommends: ceftriaxone 500mg IM x1
This is an update to the previous recommendations, which used 250mg. This reflects the changing state of antibiotic resistance of gonorrhea.
Test of cure is recommended for throat infections and for pregnant patients, but not necessarily for genital or rectal infections.
If cephalosporin allergic:
Gentamicin 240mg IM in single dose, AND Azithromycin 2g orally in single dose.
Treating chlamydia
Recommended regimen by the CDC: Doxycycline 100mg PO twice daily for 7 days.
Alternative regimens include:
Azithromycin 2g orally, single dose
Levofloxacin 500 mg orally for 7 days
Azithromycin has lower efficacy amongst persons with concomitant rectal infection, which is why the doxycycline regimen is preferred.
Repeat screening may be needed to ensure efficacy of the single-dose azithro regimen.
Expedited partner treatment - treat the sexual partner of the patient diagnosed with chlamydia or gonorrhea without first examining the sexual partner
CDC says: EPT is a useful option to facilitate partner management in states where it is permissible, and reduces re-infection risk for the patient while treating the partner.
Should always counsel the patient that partner and patient should refrain from having intercourse for at least 7 days after all partners have been treated.
GC/chlamydia in pregnancy
Screen in first trimester and if positive, should be treated
Exception: for chlamydia, Azithromycin 1g orally x1 is the recommended regimen.
These medications are safe during pregnancy, and risks outweigh the benefits of not treating
Expedited partner treatment is recommended where permissible.
Test of cure is recommended in three weeks (and should also screen in 3rd trimester again)
Pregnancy-specific risks of non-treatment
Vertical transmission to newborn
Chlamydia: conjunctivitis (5-14 days after birth), and pneumonia (4-12 weeks of age)
Gonorrhea: conjunctivitis (more purulent compared to watery discharge of chlamydia… both can lead to blindness!)
Gentamicin/erythomycin eye gel helps to prevent these and why we use it!
Otherwise: septic abortions, intact chorio, etc.
A final “fun fact” we had dug out in the original GC/CT episode…
There is no consensus as to why gonorrhea is called the clap… but some theories:
Old English word “clappan” means throbbing or beating -- could mean the burning during urination with gonorrhea
Proposed treatment during medieval times of “clapping” the penis or slamming the penis between both hands on a hard surface to get rid of the discharge/pus
