The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors; see Clinical Considerations for further discussion of risk factors). B recommendation
Women with asymptomatic gonorrhea infection have high morbidity due to pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain. Pregnant women with gonorrhea infection are at risk for preterm rupture of membranes, preterm labor, and chorioamnionitis. There is fair evidence that screening tests can accurately detect gonorrhea infection and good evidence that antibiotics can cure gonorrhea infection. There is fair evidence that screening pregnant women at high risk for gonorrhea, including women at high risk because of younger age, may prevent other complications associated with gonococcal infection during pregnancy, such as preterm delivery and chorioamnionitis. Potential harms of screening and treatment for gonorrhea include false-positive test results, anxiety, and unnecessary antibiotic use. There is insufficient evidence (due to a lack of studies) to quantify the magnitude of these potential harms. The USPSTF judges the magnitude of the potential harms to be small. The USPSTF concludes that the benefits of screening women at increased risk for gonorrhea infection outweigh the potential harms.
The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in men at increased risk for infection (see Clinical Considerations for discussion of risk factors). I recommendation
The morbidity from undiagnosed and untreated genital gonorrhea infection is lower in men than in women. Clinical symptoms are more likely to lead to diagnosis and treatment in men; thus, the prevalence of asymptomatic infection in men is lower. There is fair evidence that non-invasive screening tests can accurately detect gonorrhea infection and good evidence that antibiotics cure gonorrhea infection. Potential harms of screening and treatment for gonorrhea include false-positive test results, anxiety, and unnecessary antibiotic use. There is insufficient evidence (due to a lack of studies) to quantify the magnitude of these potential harms. The USPSTF judges the magnitude of the potential harms of screening men for gonorrhea to be small. Given the low prevalence of asymptomatic infection in men, the USPSTF could not determine the balance of benefits and harms of screening for gonorrhea infection in men at increased risk for infection.
The USPSTF recommends against routine screening for gonorrhea infection in men and women who are at low risk for infection (see Clinical Considerations for discussion of risk factors). D recommendation
There is a low prevalence of gonorrhea infection in the general population and consequently a low yield from screening. Thus, the USPSTF concludes that potential harms of screening (i.e., false-positive test results and labeling) in low-prevalence populations outweigh the benefits.
The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in pregnant women who are not at increased risk for infection (see Clinical Considerations for discussion of risk factors). I recommendation
The prevalence of gonorrhea infection in pregnant women who are not at increased risk for infection is low. The USPSTF could not determine the balance between benefits and harms of screening for gonorrhea in pregnant women who are not at increased risk for infection.
The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. A recommendation.
There is good evidence that blindness due to gonococcal ophthalmia neonatorum has become rare in the United States since the implementation of universal preventive medication of infants.
Clinical Considerations
- Women and men under the age of 25--including sexually active adolescents--are at highest risk for genital gonorrhea infection. Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use. Risk factors for pregnant women are the same as for non-pregnant women. Prevalence of gonorrhea infection varies widely among communities and patient populations. African Americans and men who have sex with men have a higher prevalence of infection than the general population in many communities and settings.
- Individual risk depends on the local epidemiology of disease. Local public health authorities provide guidance to clinicians to help identify populations who are at increased risk in their communities. In communities with a high prevalence of gonorrhea, broader screening of sexually active young people may be warranted, especially in settings serving individuals who are at increased risk. Additionally, clinicians may want to consider other population-based risk factors, including residence in urban communities and communities with high rates of poverty, when making screening decisions. Low community prevalence of gonorrhea infection may justify more targeted screening.
- Screening is recommended at the first prenatal visit for pregnant women who are in a high risk group for gonorrhea infection. For pregnant patients who are at continued risk, and for those who acquire a new risk factor, a second screening should be conducted during the third trimester. The optimal interval for screening in the non-pregnant population is not known.
- Vaginal culture remains an accurate screening test when transport conditions are suitable. Newer screening tests, including nucleic acid amplification tests and nucleic acid hybridization tests, have demonstrated improved sensitivity and comparable specificity when compared with cervical culture. Some newer tests can be used with urine and vaginal swabs, which enables screening when a pelvic examination is not performed.
- Appropriate treatment of gonorrhea infection and administration of prophylactic medication to newborns have been outlined by the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/std/treatment/4-2002TG.htm#Gonococcal). Genital infection in men and women may be treated with a third generation cephalosporin or fluoroquinolone, and pregnant women may be treated with third generation cephalosporins. Because of emerging fluoroquinolone resistance, the CDC issued new treatment guidelines in 2004 recommending that men who have sex with men and those who acquired an infection in California, Hawaii, or Asia not be treated with fluoroquinolone antibiotics. If clinicians have not concurrently screened for chlamydial infection, the CDC recommends presumptive treatment for chlamydia at the time of treatment for gonorrhea. In order to prevent recurrent transmission, partners of infected individuals should be tested and treated if infected, or treated presumptively.
- Gonorrhea is a nationally reportable condition. More complete reporting of gonorrhea cases to public health authorities will permit more accurate estimations of gonorrhea prevalence. Improved information will allow clinicians to screen for gonorrhea in ways that improve the balance between benefits and harms for their patients.
- Research priorities for gonorrhea screening include greater understanding of the benefits of screening men at increased risk, especially men who have sex with men, and the role of reporting on gonorrhea rates and testing priorities.
- See other USPSTF recommendations on screening for sexually transmitted infections (chlamydial infection, hepatitis B and C virus infection, HIV, genital herpes simplex, and syphilis) at http://www.ahrq.gov/clinic/cps3dix.htm#infectious.
Definitions:
Strength of Recommendations
The USPSTF grades its recommendations according to one of 5 classifications
(A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit
(benefits minus harms):
A
The USPSTF strongly recommends that clinicians provide [the service] to
eligible patients. The USPSTF found good evidence that [the service] improves
important health outcomes and concludes that benefits substantially outweigh
harms.
B
The USPSTF recommends that clinicians provide [the service] to eligible
patients. The USPSTF found at least fair evidence that [the service] improves
important health outcomes and concludes that benefits outweigh harms.
C
The USPSTF makes no recommendation for or against routine provision of [the
service]. The USPSTF found at least fair evidence that [the service] can improve
health outcomes but concludes that the balance of benefits and harms is too
close to justify a general recommendation.
D
The USPSTF recommends against routinely providing [the service] to
asymptomatic patients. The USPSTF found at least fair evidence that [the
service] is ineffective or that harms outweigh benefits.
I
The USPSTF concludes that the evidence is insufficient to recommend for or
against routinely providing [the service]. Evidence that [the service] is
effective is lacking, of poor quality, or conflicting and the balance of
benefits and harms cannot be determined.
Strength of Evidence
The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):
Good
Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair
Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor
Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
