Gonorrhoea (colloquially known as "clap") is caused by the bacterium Neisseria gonorrhoeae. Gonorrhoea is the second most common bacterial sexually transmitted infection after chlamydia.

Worldwide

Human

Transmission occurs through direct mucosal contact with infectious secretions and can therefore occur during all forms of sexual intercourse (vaginal, oral and anal) or during birth from an infected mother to the child.

In women, the symptoms are often mild (vaginal discharge or light vaginal bleeding) or even absent. Ascending infections can lead to pelvic inflammatory disease (inflammation of the endometrium, fallopian tubes or peritoneum) and subsequently to infertility or complications in early pregnancy (extrauterine pregnancy).

In men, infection with gonococci manifests itself with discharge of purulent secretion from the urethra and burning when urinating. In contrast to infections in women, only a small proportion of cases in men are asymptomatic.

Infections of the rectum and oral cavity and, in rare cases, of the eye are also possible. Untreated infections can lead to a disseminated gonococcal infection, which can be accompanied by joint inflammation (arthritis), skin changes and, rarely, heart valve inflammation (endocarditis) or meningitis.

Gonorrhoea is treated with antibiotics. In the case of uncomplicated gonorrhoea, a single administration of an antibiotic (by injection into the muscle or vein) is usually sufficient.

The most important preventive measure to avoid transmission is the correct use of condoms during sexual contact or adherence to "safer sex" rules. There are no specific vaccines to prevent gonorrhoea.

In 2020, 269 gonococcal isolates from 263 patients were analysed at the National Reference Centre. There is a limited obligation to report gonorrhoea if there is a risk of it spreading or if patients evade treatment. The disease is not generally notifiable, which is why there are no official case numbers in this country.

Symptoms

In women, the symptoms are often mild (vaginal discharge or light vaginal bleeding) or even absent. Ascending infections can lead to pelvic inflammatory disease (inflammation of the endometrium, fallopian tubes or peritoneum) and subsequently to infertility or complications in early pregnancy (extrauterine pregnancy).

In men, infection with gonococci manifests itself with discharge of purulent secretion from the urethra and burning when urinating. In contrast to infections in women, only a small proportion of cases in men are asymptomatic.

Infections of the rectum and oral cavity are also possible. Rectal infections may be asymptomatic or may manifest as pain, purulent discharge, bleeding or anal itching. Symptomatology of oral cavity infections is often mild to absent; asymptomatic individuals with rectal or pharyngeal (throat) colonization are therefore a common undetected source of infection, especially in homosexual men (MSM = men who have sex with men).

Eye infections can occur in newborns through infection during the birth process, in adults through smear infections and usually manifest themselves as purulent conjunctivitis or keratoconjunctivitis.

Untreated infections can lead to a disseminated gonococcal infection, which can be accompanied by joint inflammation (arthritis), skin changes and, rarely, inflammation of the heart valves (endocarditis) or meningitis.

Therapy

Gonococci are characterised by a rapid development of resistance to antibiotics. While penicillin has no longer been the drug of choice since 1989 and fluoroquinolones (gyrase inhibitors) have also shown increasingly high resistance rates over the past 10 years (now over 50%), a continuous reduction in sensitivity to azithromycin and cephalosporins with an extended spectrum of activity has also been observed in recent years, which is increasingly associated with clinical treatment failure under oral cephalosporin (cefixime), which is why particular attention must be paid to the development of resistance.

Isolated cases of resistance to ceftriaxone have been reported in some countries. Fortunately, no ceftriaxone-resistant isolate has yet been detected in Austria and, as in other European countries, the resistance rate to cefixime has decreased in recent years, which can be attributed to a change in treatment guidelines (ceftriaxone instead of cefixime).

However, there has been a significant increase in the proportion of azithromycin-resistant strains in recent years. In 2020, two isolates with high-level azithromycin resistance were detected for the first time at the Austrian reference centre.

In 2022 we detected the second global XDR gonococcal strain with high-level resistance to azithromycin and resistance to ceftriaxone, cefixime, cefotaxime, ciprofloxacin, and tetracycline, which caused a possible gonorrhoea treatment failure with recommended ceftriaxone plus azithromycin therapy.

In 2020, the treatment guidelines for uncomplicated genital, pharyngeal and rectal gonorrhoea were adapted or amended by both the European Centre for Disease Prevention and Control (ECDC) and the US Centers for Disease Control and Prevention (CDC):

• ECDC: ceftriaxone (1g i.m. or i.v.) plus azithromycin (2g p.o.) as a single dose.
• CDC: Ceftriaxone 500 mg i.m. as a single dose (plus doxycycline 2x100 mg p.o. for 7 days if coinfection with Chlamydia trachomatis is proven or possible).

For details, please refer to the original texts: Unemo M, Ross J, Serwin AB, Gomberg M, Cusini M, Jensen JS. 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS. 2020;0(0):1-17. St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-6.

The WHO recommends that antibiotics with a resistance rate of more than 5% should no longer be used in empirical therapy. In Austria, we have observed azithromycin resistance rates of over 10 % in recent years. Therefore, in our view, combination therapy can be dispensed with in therapy-naïve patients and monotherapy with ceftriaxone (if necessary in combination with doxycycline) can be administered.

Indication for therapy

• Cultural or molecular biological detection of Neisseria gonorrhoeae
• Microscopic detection (Gram or methylene blue stain) of intracellular diplococci from the genital tract with a corresponding sexual history, after prior collection of material for pathogen diagnosis.
• In the case of purulent urethral discharge (men and women) or in the case of mucopurulent cervicitis with a corresponding sexual history, also without pathogen detection (if rapid diagnosis is not possible), after prior collection of material for pathogen diagnosis.
• Purulent eye inflammation (ophthalmoblenorrhoea)
• Sexual partners of infected persons (if necessary also without prior diagnosis)

All patients should be informed about the infections, as well as transmission possibilities, prevention and therapy. Ideally, this should be done both orally and in writing. Information for patients in various languages is available, for example, on the IUSTI homepage - unfortunately not in German at present.

Therapy control

Due to the resistance problem, a therapy control is recommended.

• Culture: at the earliest 72 hours after completion of therapy
• PCR: at the earliest 3 weeks after completion of therapy.

In 2016, the Institute for Medical Microbiology and Hygiene of the AGES in Vienna took over the tasks of a National Reference Centre for Neisseria gonorrhoeae. Among other things, the monitoring of antimicrobial susceptibility as well as the collection of epidemiological data, in cooperation with national and international partners, is an essential part of the tasks of the reference centre, especially since the resistance situation can change relatively quickly, resulting in changes in therapy recommendations. The preparation of annual reports and the provision of advice to physicians are further components of this work. The current resistance situation can be found in the annual report of the reference centre or in the AURES. Together with our tasks as a reference centre, we have also taken over the Austrian representation in the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP). Within the framework of this project, gonococcal isolates including epidemiological data from several European countries are collected annually for supraregional resistance testing. We are supported in the collection and resistance testing of gonococcal strains as well as in recommendations for therapy and diagnostics by the Microbiological Laboratory Möst, Innsbruck. The tasks of the reference centre include:

• Cultivation of Neisseria gonorrhoeae
• Detection of Neisseria gonorrhoeae by molecular biological methods
• Outbreak clarification
• Participation in European ring trials
• Management of a reference strain collection
• Advice on diagnostics, epidemiology, therapy, measures and prevention
• Reporting
• Monitoring the development of antibiotic resistance

Within the framework of our reference activities, we ask microbiological laboratories/hospitals to send us gonococcal isolates. A resistance test according to the guidelines of EUCAST (European Committee on Antimicrobial Susceptibility Testing) is carried out free of charge for the sender and the isolates are whole-genome sequenced in selected cases (resistant strains). Fresh cultures in transport media (e.g. VWR Transystem amies with CH Aluminium applicator rayon tipped) are best suited for shipping the strains. Please use the appropriate submission form with the appropriate reference to the medical diagnostic examination material as well as the necessary patient data, clinical and epidemiological data. In addition, gonococcal isolates can be sent with a referral form to the MB-LAB - Microbiological Laboratory (Dr. Eigentler, Tel.: +43 (0)512-563380, Franz-Fischer-Straße 7b, 6020 Innsbruck). Please also use the corresponding submission form with the appropriate reference to the medical-diagnostic examination material as well as the necessary patient data, clinical and epidemiological data.