Gonococcal Pharyngitis

Background

• Gonococcal pharyngitis refers to infection of the pharynx with Neisseria gonorrhoeae.
• Prevalence is about 2%-7% in sexually transmitted disease clinic attendees, regardless of symptoms.
• Oral receptive sex is the main mode of transmission.
• Infection is usually asymptomatic but, when present, symptoms are similar to pharyngitis of other causes and may include
  • sore throat
  • fever
  • cervical lymphadenopathy
• Infection can be more difficult to eradicate from the pharynx than from urogenital sites.
• Coinfection with Chlamydia trachomatis can occur in the pharynx but is less common than coinfection at other sites.

Evaluation

• Suspect gonococcal pharyngitis in patients with history of receptive oral intercourse and pharyngitis.
• Annually screen for gonorrhea from pharynx in men who have sex with men who have had receptive oral sex in prior 12 months.
• Diagnostic testing options, using pharyngeal swab, include
  • nucleic acid amplification testing
    • recommended by the European International Union against Sexually Transmitted Infections and World Health Organization (IUSTI/WHO)
    • may be more sensitive than traditional culture for detection of gonococcal pharyngitis
  • culture
    • traditional gold standard
    • allows for antimicrobial susceptibility testing
• Gram stain of pharyngeal samples is insufficient to assess for infection.
• All patients with suspicion for sexually transmitted infections should also be tested for Chlamydia trachomatis, syphilis, and HIV.

Management

• First-line recommendations from Centers for Disease Control and Prevention (CDC) for adults with uncomplicated gonococcal pharyngitis consists of a single dose of ceftriaxone:
  • 500 mg intramuscularly in a single dose for patients weighing < 150 kg (300 lbs)
  • 1 g intramuscularly in a single dose for patients weighing ≥ 150 kg (300 lbs)
  • if chlamydial coinfection has not been excluded, additional treatment recommended:
    • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
    • for pregnant patients, give azithromycin 1 g orally in a single dose
• Due to the emergence of drug-resistant gonococci
  • CDC no longer recommends oral cephalosporins as first line therapy for the treatment of gonorrhea and no longer recommends empiric azithromycin if chlamydial coinfection has been ruled out.
  • European International Union against Sexually Transmitted Infections/World Health Organization recommends higher-dose therapy with ceftriaxone 1 g intramuscularly PLUS azithromycin 2 g orally in a single dose.
  • Alternatives to cephalosporins include spectinomycin, gentamicin, and higher-dose azithromycin but each has limitations.
• Counsel patients to avoid sexual activity until ≥ 7 days after treatment is complete and both patient and partner no longer have symptoms.
• Treatment recommendations do not differ for patients with HIV.
• Patients should be instructed to refer sex partners for evaluation and treatment.
• Infection may be more difficult to eradicate from the pharynx than from urogenital sites, though reported cure rate 98.9% with currently recommended therapy.
• All patients treated for gonococcal pharyngitis should have test-of-cure with culture or nucleic acid amplification test at 7-14 days.