The correct answer is:

Azithromycin was dropped from all recommended regimens for this type of gonococcal infection.

Educational Objective:

Discuss treatment of a disseminated gonococcal infection in an adult.

Key Point:

This patient has disseminated gonococcal infection (DGI) presenting as the gonococcal arthritis-dermatitis syndrome, for which the 2021 guidelines of the CDC recommend hospitalization (at least initially), infectious disease consult, and ceftriaxone 1 gm IM or IV every 24 hours.

This is a change from the 2015 guidelines, which recommended dual antibiotics with ceftriaxone 1 gm IM or IV every 24 hours PLUS azithromycin 1 gm PO as a single dose).

Cefotaxime 1 g IV every 8 hours or Ceftizoxime 1 g IV every 8 hours are the only acceptable alternatives listed specifically for DGI presenting as the gonococcal arthritis or arthritis-dermatitis syndrome.

For DGI complicated by endocarditis or meningitis, ceftriaxone and infectious disease consult are the only recommended treatment approaches.

Explanation:

DGI usually presents as an arthritis or arthritis-dermatitis syndrome. Rarely, DGI is complicated by perihepatitis, usually in conjunction with gonococcal PID, endocarditis, or meningitis.

Different from the strains that cause classic primary gonorrhea, the strains of N. gonorrhoeae that cause DGI are often associated with minimal primary symptoms of genital inflammation or urogenital or anorectal symptoms (such as purulent discharge). Symptoms of primary gonorrhea are therefore often not recalled by the patient who presents with DGI.

If DGI is suspected, NAATs or culture specimens from all possible exposed urogenital and anal sites should be collected and processed (in addition to specimens from disseminated sites of infection such as skin, synovial fluid, blood, or CSF). All N. gonorrhoeae isolates from these various sites should be tested for antimicrobial susceptibility since various strains may be involved.

Risk factors for dissemination include female sex, menstruation, pregnancy, and terminal complement deficiency; however, reports of DGI are now also increasing among men. Persons receiving eculizumab, a monoclonal antibody that inhibits terminal complement activation, also might be at higher risk for DGI.

Hospitalization and consultation with an infectious disease specialist are recommended for initial treatment of DGI, especially for persons who might not comply with treatment, have an uncertain diagnosis, or have purulent synovial effusions or other complications.

Examination for clinical evidence of endocarditis and meningitis should be performed.

If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg po bid for seven days.

Mostly, N. gonorrhoeae has become resistant to fluoroquinolones and tetracyclines.  Azithromycin 2 gm orally as a single dose in combination with gentamicin 240 mg IM as a single dose is an acceptable alternative to ceftriaxone for the treatment of uncomplicated gonorrhea. It is not an acceptable alternative treatment for DGI.

References:

Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70 (No. RR-4):1–187. (updated July 22, 2021) (Accessed September 03, 2021)

Workowski KA, Bolan GA. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015; 64 (No 3): pgs 62-66. (updated June 5, 2015; note: these guidelines are still valid for disseminated gonorrhea, but no longer for uncomplicated gonorrhea) (Accessed July 13, 2021).