Screening Patients for Gonococcal and Chlamydial Infections
Clinicians should screen sexually active human immunodeficiency virus (HIV)-infected women under the age of 25 for gonorrhea and chlamydia at baseline and at least annually. Clinicians should obtain a sexual history to determine the sites of possible exposures, and all sites of exposure should be screened. Culture or nucleic acid amplification tests (NAAT) should be used to screen for gonorrhea. Immunofluorescence or DNA amplification should be used for chlamydia.
Clinicians should screen women 25 years of age or older for gonorrhea and chlamydia at baseline and at least annually if they have or have had a recent sexually transmitted infection, have multiple sexual partners, have had a new sexual partner, or have a sexual partner with symptoms of a sexually transmitted infection (STI).
Clinicians should screen HIV-infected men who have sex with men with ongoing high-risk behaviors for gonorrhea and chlamydia at baseline and at least annually. Clinicians should obtain a sexual history to determine the sites of possible exposures, and all sites of exposure should be screened.
Refer to the Table below for information regarding annual screening of patients for gonococcal and chlamydial infection.
Table
Annual Gonorrhea and Chlamydia Screening of Asymptomatic Patients |
| Men who have sex with men |
- Urine for GC/CT NAAT and
- Rectal swab for GC culture and
- Pharyngeal swab for GC culture
|
| Women |
- Endocervical swab for GC/CT NAAT or
- Urine for GC/CT NAAT* and
- If history of rectal and/or pharyngeal exposure:
- Rectal swab for GC culture and
- Pharyngeal swab for GC culture
|
GC, gonococcal; CT, C trachomatis; NAAT, nucleic acid amplification test
*For women with previous hysterectomy, screening with urine NAAT, rather than urethral swab, may be indicated.
Diagnosis and Treatment
Clinicians managing HIV-infected patients with gonococcal and/or chlamydial infections should follow the same diagnosis and treatment recommendations as those for non-HIV-infected patients.
Clinicians should not use fluoroquinolones to treat proven or suspected gonococcal infections.
Chlamydial infections should be treated with azithromycin 1 g single dose or doxycycline 100 mg bid for 7 days. Ceftriaxone 125 mg intramuscularly (IM) is the preferred treatment for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx.
Clinicians should report all cases or suspected cases of resistance to state and local public health authorities.
Refer to the Table below for information on diagnostic tests for symptomatic patients.
Table
Diagnostic Tests for Symptomatic Patients |
| Men |
- Urethral gram stain* and
- Urine or urethral swab for GC/CT NAAT and
- If history of rectal and/or pharyngeal exposure:
- Rectal swab for GC culture and
- Pharyngeal swab for GC culture
|
| Women |
- Endocervical swab for GC/CT NAAT or
- Urine for GC/CT NAAT and
- If history of rectal and/or pharyngeal exposure:
- Rectal swab for GC culture and
- Pharyngeal swab for GC culture
|
| Persistent symptoms |
Men
- Urethral, rectal, and pharyngeal swabs for GC culture and susceptibility testing
Women
- Endocervical, rectal, and pharyngeal swabs for GC culture and susceptibility testing
|
| Follow-up after completion of treatment |
Men with proven CT
- Retest (urine NAAT) at 3 months to assess for reinfection
Men or women with uncomplicated GC
- Test of cure at 2 to 4 weeks** for evidence of resistance and
- Retest at 3 months (urine NAAT for men and endocervical swab for women) to assess for reinfection
|
| Partners |
Should be referred for treatment*** |
CT, Chlamydia trachomatis; GC, gonococcal; NAAT, nucleic acid amplification test
*White blood cell count (WBC) ≥5 per oil immersion field with evidence of gram-negative intracellular diplococci is considered diagnostic for gonococcal urethritis in symptomatic men.
**Clinicians should perform a follow-up physical examination and a test of cure from gonococcal-infected sites at 2 weeks post-treatment if using culture or at 4 weeks post-treatment if using NAAT, regardless of whether or not symptoms have resolved. If the post-treatment NAAT is positive, a culture should be performed to assess for resistance.
***Considerations of HIV exposure in the partner need to be thoroughly examined before clinicians consider prescribing expedited partner therapy. For information regarding expedited partner therapy, see http://www.cdc.gov/std/ept.
Diagnosis and Treatment of Patients with Penicillin Allergy
Clinicians should treat patients with uncomplicated gonococcal infection who have penicillin allergy, and for whom penicillin desensitization is not possible, with 2 g of azithromycin.
Treatment Follow-Up
Patients treated for confirmed gonorrhea should receive a follow-up physical examination and a test of cure from gonococcal-infected sites at 2 weeks post-treatment if using culture or at 4 weeks post-treatment if using NAAT, regardless of whether or not symptoms have resolved. If the post-treatment NAAT is positive, a culture should be performed to assess for resistance.
Clinicians should retest patients treated for confirmed gonorrhea or chlamydial infection at least 3 months after treatment completion for evidence of reinfection.
Key Point:
The majority of infections identified after treatment with one of the recommended regimens result from reinfection rather than treatment failure, demonstrating the importance of retesting for new infection at 3 months after completion.
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Management of Sex Partners
Clinicians should consider both the HIV exposure and the STI exposure to partners when HIV-infected patients present with a new STI. Clinicians should also assess for the presence of other STIs.
Management of HIV Exposure
When HIV-infected patients present with a new STI, clinicians should encourage their partner(s) to undergo HIV testing at baseline, 1, 3, and 6 months. In New York State, if the test result is positive, a Western blot assay must be performed to confirm diagnosis of HIV infection.
Clinicians should be vigilant for any post-exposure acute febrile illness accompanied by rash, lymphadenopathy, myalgias, and/or sore throat. If the partner presents with signs or symptoms of acute HIV seroconversion, a quantitative ribonucleic acid polymerase chain reaction (RNA PCR) should be obtained, and consultation with an HIV Specialist should be sought. Positive RNA tests should be confirmed with HIV antibody testing performed within 6 weeks of the RNA test.
Clinicians should offer assistance with partner notification if needed.
Management of Gonococcal and/or Chlamydial Exposure
Sex partners of patients with gonococcal and/or chlamydial infections should be treated or referred for treatment if the partner was exposed within 60 days prior to symptom onset.
