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.

Every year, 200-400 gonococcal isolates are analysed at the National Reference Centre as part of a sentinel system and the analysis results are published in the annual report. 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 inflammation of the small pelvis (inflammation of the uterine lining, 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 secretions from the urethra and a burning sensation when urinating. In contrast to infections in women, only a small proportion of cases in men are asymptomatic.

Infections of the rectum and the oral cavity are also possible. Rectal infections can be asymptomatic or manifest themselves through pain, purulent discharge, bleeding or anal itching. The symptoms of infections of the oral cavity are often mild to absent, asymptomatic persons with rectal or pharyngeal (throat) colonisation are therefore a frequent unrecognised source of infection, especially in homosexual men (MSM = men who have sex with men).

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

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.

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 ever higher resistance rates in 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.

Individual cases of resistance to ceftriaxone have been reported in some countries.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 in Austria, which led to a possible failure of gonorrhoea treatment with the recommended therapy of ceftriaxone plus azithromycin.

In Austria, no other ceftriaxone-resistant isolate has been detected to date. 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).

Due to these developments, the continuous monitoring of the resistance situation - nationally and globally - is of considerable importance. The National Reference Centre for Neisseria gonorrhoeae therefore monitors the antimicrobial susceptibility of 200-400 gonococcal isolates annually. The current resistance situation can be found in the annual report of the reference centre or the AURES. In addition to our duties as a reference centre, we are also the Austrian representative in the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP). As part of this project, gonococcal isolates including epidemiological data are collected annually from several European countries for supra-regional resistance testing. Further information on national surveillance can be found here.

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) and provide helpful guidance on treatment selection:

• 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

Indication for therapy

• Cultural or molecular biological detection of Neisseria gonorrhoeae
• Microscopic detection (Gram or methylene blue staining) of intracellular diplococci from the genital tract with a corresponding sexual history, after prior collection of material for pathogen diagnostics
• In the case of purulent urethral discharge (men and women) or 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 inflammation of the eye (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 treatment. Ideally in both oral and written form. Patient information in various languages is available, for example, on the IUSTI homepage - unfortunately not currently in German.

Therapy monitoring

Due to the problem of resistance, therapy monitoring is recommended.

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