WHO issues new treatment guidelines for Gonorrhea, Chlamydia and Syphilis (30 August 2016)- Part 1: Gonorrhea

The World Health Organization (WHO) has recently released new treatment guidelines for the treatment of three Sexually Transmitted Infections (STIs)- Gonorrhea, Chlamydia, and Syphilis.

The new treatment guidelines have been issued in view of the growing threat of antibiotic resistance.

This post will present the guidelines for Gonorrhea. Subsequent posts will present the guidelines for Syphilis and Chlamydia, respectively.

Background Information:

Gonorrhea:

Gonorrhoea, caused by Neisseria gonorrhoeae, is the second most common bacterial STI and results in substantial morbidity and economic cost worldwide.

Uncomplicated gonococcal infection commonly manifests as urethritis in men and may cause mucopurulent cervicitis in women.

Rectal and pharyngeal infections in both men and women are largely asymptomatic.

Gonococcal infections are often asymptomatic in women; the lack of discernible symptoms results in unrecognized and untreated infection that may lead to serious complications, including

  • pelvic inflammatory disease,
  • ectopic pregnancy and
  • infertility.

Untreated urethral infection in men can lead to

  • epididymitis,
  • urethral stricture and
  • infertility.

Infants of mothers with gonococcal infection can contract neonatal conjunctivitis, which may lead to blindness if left untreated.

Key Messages:

The objectives of these guidelines are:

  • to provide evidence-based guidance on treatment of infection with N. gonorrhoeae; and
  • to support countries to update their national guidelines for treatment of gonococcal infection.

The guidelines provide six treatment recommendations for specific conditions caused by N. gonorrhoeae.

The recommendations for sexually transmitted gonococcal infections apply to all adults and adolescents (10–19 years of age), including

  • people living with HIV and key populations, including
  • sex workers,
  • men who have sex with men, 
  • transgender persons and
  • pregnant women.

Specific recommendations are also provided for prophylaxis and treatment of ophthalmia neonatorum caused by N. gonorrhoeae.

Notable changes from the 2003 WHO STI guidelines include the following:

  1. quinolones are no longer recommended for the treatment of gonorrhoea due to the reported high level of resistance;
  2. there are now recommendations for oropharygeal infections, and
  3. retreatment of gonococcal infections after treatment failure;
  4. dual therapy is a preferred option for treatment of gonococcal infections over single therapy;
  5. single therapy is based on local resistance data and changes have been made to some dosages; and
  6. new topical medications have been suggested for prophylaxis of ophthalmia neonatorum.

The Recommendations

I. Genital and anorectal gonococcal infections

The WHO STI guideline recommends that local resistance data should determine the choice of therapy (both for dual therapy and single therapy).

In settings where local resistance data are not available, the WHO STI guideline suggests dual therapy over single therapy for people with genital or anorectal gonorrhoea.

The WHO STI guideline suggests the following options:

Dual therapy (one of the following)

  • ceftriaxone 250 mg intramuscular (IM) as a single dose PLUS azithromycin 1 g orally as a single dose
  • cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose

Single therapy (one of the following, based on recent local resistance data confirming susceptibility to the antimicrobial)

  • ceftriaxone 250 mg IM as a single dose
  • cefixime 400 mg orally as a single dose
  • spectinomycin 2 g IM as a single dose.

II. Oropharyngeal gonococcal infections

In adults and adolescents with gonococcal oropharyngeal infections, the WHO STI guideline suggests dual therapy over single therapy.

The WHO STI guideline suggests the following options:

Dual therapy (one of the following)

  • ceftriaxone 250 mg intramuscular (IM) as a single dose PLUS azithromycin 1 g orally as a single dose
  • cefixime 400 mg orally as a single dose PLUS azithromycin 1 g orally as a single dose

Single therapy (based on recent local resistance data confirming susceptibility to the antimicrobial)

  • ceftriaxone 250 mg IM as single dose.

III. Retreatment of gonococcal infections after treatment failure

In people with gonococcal infections who have failed treatment, the WHO STI guideline suggests the following options.

  • If reinfection is suspected, re-treat with a WHO-recommended regimen, reinforce sexual abstinence or condom use, and provide partner treatment.
  • If treatment failure occurred after treatment with a regimen not recommended by WHO, re-treat with a WHO-recommended regimen.
  • If treatment failure occurred and resistance data are available, re-treat according to susceptibility.
  • If treatment failure occurred after treatment with a WHO-recommended single therapy, re-treat with WHO-recommended dual therapy.
  • If treatment failure occurred after a WHO-recommended dual therapy, re-treat with one of the following dual therapies:
  1. ceftriaxone 500 mg IM as a single dose PLUS azithromycin 2 g orally as a single dose
  2. cefixime 800 mg orally as a single dose PLUS azithromycin 2 g orally as a single dose
  3. gentamicin 240 mg IM as a single dose PLUS azithromycin 2 g orally as a single dose
  4. spectinomycin 2 g IM as a single dose (if not an oropharyngeal infection) PLUS azithromycin 2 g orally as a single dose.

IV. Gonococcal ophthalmia neonatorum

In neonates with gonococcal conjunctivitis, the WHO STI guideline suggests one of the following treatment options:

  • ceftriaxone 50 mg/kg (maximum 150 mg) IM as a single dose
  • kanamycin 25 mg/kg (maximum 75 mg) IM as a single dose
  • spectinomycin 25 mg/kg (maximum 75 mg) IM as a single dose.

V. Topical ocular prophylaxis against ophthalmia neonatorum for neonates

For all neonates, the WHO STI guideline recommends topical ocular prophylaxis for the prevention of gonococcal and chlamydial ophthalmia neonatorum.

VI. Ocular prophylaxis of ophthalmia neonatorum

For ocular prophylaxis, the WHO STI guideline suggests one of the following options for topical application to both eyes immediately after birth:

  • tetracycline hydrochloride 1% eye ointment
  • erythromycin 0.5% eye ointment
  • povidone iodine 2.5% solution (water-based)
  • silver nitrate 1% solution
  • chloramphenicol 1% eye ointment.

V and VI are applicable to both gonococcal and chlamydial ophthalmia neonatorum.

DO NOT USE ALCOHOL-BASED POVIDONE IODINE SOLUTION.

Useful Links:

Link to the WHO media release:

http://www.who.int/mediacentre/news/releases/2016/antibiotics-sexual-infections/en/

Link to the revised guidelines (English) [PDF]:

http://apps.who.int/iris/bitstream/10665/246114/1/9789241549691-eng.pdf?ua=1

Link to Annex D (Evidence profiles and evidence-to-decision frameworks)(English)[PDF]:

http://apps.who.int/iris/bitstream/10665/246114/5/9789241549691-annexD-eng.pdf?ua=1

Link to Annex F (Summary of conflicts of interest)(English)[PDF]:

http://apps.who.int/iris/bitstream/10665/246114/7/9789241549691-annexF-eng.pdf?ua=1

 

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4 thoughts on “WHO issues new treatment guidelines for Gonorrhea, Chlamydia and Syphilis (30 August 2016)- Part 1: Gonorrhea

  1. Pingback: WHO issues new treatment guidelines for Gonorrhea, Chlamydia and Syphilis (30 August 2016)- Part 2: Chlamydia | communitymedicine4asses

  2. Pingback: WHO releases new guidelines for the treatment of Gonorrhea, Chlamydia and Syphilis (30 August 2016)- Part 3: Syphilis | communitymedicine4asses

  3. Pingback: Taking on Superbugs, Syphilis and Gonorrhoeae with Iodine

  4. Pingback: Taking on Superbugs, Syphilis and Gonorrhoeae with Iodine – Your-Health-and-Fitness.Com

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