Gonorrhea guide: Screening and diagnostic testing

Screening and diagnostic testing guidance for Neisseria gonorrhoeae infections

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Screening

Screening for N. gonorrhoeae is recommended for anyone presenting with risk factors for STI. Screening is effective for detecting and treating asymptomatic infections as well as preventing complications, transmission and reinfection. Depending on the type of sexual activity, it may be necessary to collect specimens from multiple anatomical sites.

Adolescents and young adults

Screen sexually active people under 25.

Pregnant people

Screen all pregnant people at the first prenatal visit. If gonococcal infection is diagnosed, TOC is recommended.

Rescreen at third trimester:

Screen at delivery

Neonates

Other STBBIs

STBBI screening recommendations vary by age, gender/sex, medical and sexual history. Any person with STBBI risk factors should be screened for STBBIs and treated appropriately to prevent transmission and reinfection.

People with N. gonorrhoeae often have a co-infection with C. trachomatisFootnote 1Footnote 2Footnote 3.

Gonorrhea can increase the risk of HIV acquisition and transmissionFootnote 4Footnote 5Footnote 6.

People being evaluated or treated for a gonorrhea infection should be screened for:

Diagnostic testing

Clinical presentation and sexual history determine which specimens should be collected and the type of test to use. Laboratory tests for the diagnosis of gonorrhea may include culture, NAAT and microscopy (Gram stain).

Note:

Nucleic acid amplification tests (NAATs)

NAATs are the most sensitive tests for N. gonorrhoeaeFootnote 7Footnote 8 and may increase the number of cases diagnosedFootnote 8Footnote 9.

NAAT may be done without waiting 48 hours post-exposure. This is based on expert opinion that NAAT can detect small amounts of DNA or RNA (inoculum).

Validated NAAT can be used to detect rectal and pharyngeal infections.

Some NAATs may generate false positive results due to possible cross-reaction with other Neisseria species. If a false positive result is suspected, consult with your laboratory for further guidance.

Culture

Culture provides antimicrobial susceptibilities and should be used when antibiotic resistance is suspected. Culture provides important case management information and is critical for improved public health monitoring of AMR patterns and trendsFootnote 10Footnote 11Footnote 12Footnote 13Footnote 14Footnote 15.

Since NAATs are more sensitive than culture, consider collecting specimens for both culture and NAAT where feasible.

Culture is strongly recommended (together with NAAT) in the following situations:

Culture is also recommended (together with NAAT) in the following situations:

Footnote *

Consult with provincial and territorial guidelines or local laboratory regarding the use of culture and NAAT for medico-legal purposes.

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Gram stain

The presence of Gram-negative intracellular diplococci (GNID) seen on direct microscopic examination of urethral smears is highly predictive of N. gonorrhoeae in symptomatic menFootnote 17.

The sensitivity and specificity of the Gram stain depends on the type of specimenFootnote 17.

Recommended specimens and tests for N. gonorrhoeae

Specimens and tests for urogenital sites (urethral, endocervical, vaginal)

Asymptomatic people:

NAAT is the screening test of choice.

Test Specimens for asymptomatic malesFootnote 9 Specimens for asymptomatic females
NAAT

First-void urine
or
Urethral swab

Vaginal swab, self-obtained or collected by a clinician
or
Cervical swab
or
First-void urine

Note

Urine specimens should be first-void urine (initial 10 to 20 mL of the urine stream). Ideally, the person should not have voided for at least two hours prior to urine or urethral swab specimen collection. More recent voiding does not preclude testing.Footnote 21

Males:

Females:

Symptomatic people

Physical examination is essential when an STI is suspected. Collect specimens based on clinical presentation and sexual history, prior to treatment.

Due to high rates of concomitant infection, specimens should be collected for the diagnosis of both gonococcal and chlamydia infections by NAAT; and for culture, if available, for the diagnosis of gonococcal infectionFootnote 2Footnote 9. NAAT can detect both C. trachomatis and N. gonorrhoeae from a single specimen.

Symptomatic males:

Symptomatic females:

Specimens and tests for extragenital sites (pharyngeal and rectal)

Asymptomatic and symptomatic

Consider collecting specimens for both culture and NAAT

Pharyngeal specimens are recommended for:

Rectal specimens are recommended for:

Consider rectal screening in all gbMSM regardless of history of receptive anal intercourse (RAI)Footnote 26Footnote 27Footnote 28.

References

Footnote 1

Creighton S, Tenant-Flowers M, Taylor CB, Miller R, Low N. Co-infection with gonorrhoea and chlamydia: how much is there and what does it mean?. Int J STD AIDS. 2003;14(2):109-113. doi:10.1258/095646203321156872

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Footnote 2

Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003;139(3):178-185.

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Footnote 3

Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections [published correction appears in Am Fam Physician. 2013 Feb 1;87(3):163]. Am Fam Physician. 2012;86(10):931-938.

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Footnote 4

Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS. 1993;7(1):95-102.

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Footnote 5

Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis. Sex Transm Dis. 2008;35(11):946-959.

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Footnote 6

Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75(1):3-17.

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Footnote 7

Association of Public Health Laboratories. Laboratory diagnostic testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Expert Consultation Meeting Summary Report. January 13-15, 2009.

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Footnote 8

Kapala J, Biers K, Cox M, et al. Aptima Combo 2 testing detected additional cases of Neisseria gonorrhoeae infection in men and women in community settings. J Clin Microbiol. 2011;49(5):1970-1971.

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Footnote 9

Papp JR, Schachter J, Gaydos CA, Van Der Pol B .Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014. MMWR Recomm Rep. 2014;63(RR-02):1-19.

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Footnote 10

Centers for Disease Control and Prevention (CDC). Cephalosporin susceptibility among Neisseria gonorrhoeae isolates--United States, 2000-2010. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):873-7. PMID: 21734634.

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Footnote 11

11.Dillon JA. Sustainable antimicrobial surveillance programs essential for controlling Neisseria gonorrhoeae superbug. Sex Transm Dis. 2011;38(10):899-901. doi:10.1097/OLQ.0b013e318232459b

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Footnote 12

12.Kirkcaldy RD, Ballard RC, Dowell D. Gonococcal resistance: are cephalosporins next?. Curr Infect Dis Rep. 2011;13(2):196-204.

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Footnote 13

13.MacDonald NE, Stanbrook MB, Flegel K, Hébert PC, Rosenfield D. Gonorrhea: what goes around comes around. CMAJ. 2011;183(14):1567.

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Footnote 14

14.Tapsall JW, Ndowa F, Lewis DA, Unemo M. Meeting the public health challenge of multidrug- and extensively drug-resistant Neisseria gonorrhoeae. Expert Rev Anti Infect Ther. 2009;7(7):821-834.

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Footnote 15

15.Unemo M, Shipitsyna E, Domeika M; Eastern European Sexual and Reproductive Health (EE SRH) Network Antimicrobial Resistance Group. Recommended antimicrobial treatment of uncomplicated gonorrhoea in 2009 in 11 East European countries: implementation of a Neisseria gonorrhoeae antimicrobial susceptibility programme in this region is crucial. Sex Transm Infect. 2010;86(6):442-444.

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Footnote 16

16.Ng LK, Martin IE. The laboratory diagnosis of Neisseria gonorrhoeae. Can J Infect Dis Med Microbiol. 2005;16(1):15-25. 18.

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Footnote 17

17.Ison C LD. Gonorrhea. In: Morse S, Ballard R, Holmes K, Moreland A, ed. Atlas of sexually transmitted diseases and AIDS. 4th ed ed. Netherlands: Elsevier; 2010:24-39.

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Footnote 18

18.Lahra MM, Martin I, Demczuk W, et al. Cooperative Recognition of Internationally Disseminated Ceftriaxone-Resistant Neisseria gonorrhoeae Strain. Emerg Infect Dis. 2018;24(4):735-740. doi:10.3201/eid2404.171873

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Footnote 19

19.Lefebvre B, Martin I, Demczuk W, et al. Ceftriaxone-Resistant Neisseria gonorrhoeae, Canada, 2017. Emerg Infect Dis. 2018; 24(2):381-383. doi:10.3201/eid2402.171756

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Footnote 20

20.Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Genitourin Med. 1996;72(6):422-426.

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Footnote 21

21.Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014. MMWR Recomm Rep. 2014;63(RR-02):1-19.

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Footnote 22

22.Schachter J, McCormack WM, Chernesky MA, et al. Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia trachomatis. J Clin Microbiol. 2003;41(8):3784-3789.

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Footnote 23

23.Manavi K, Young H. The significance of voiding interval before testing urine samples for Chlamydia trachomatis in men. Sex Transm Infect. 2006;82(1):34-36.

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Footnote 24

24.Mathew T, O'Mahony C, Mallinson H. Shortening the voiding interval for men having chlamydia nucleic acid amplification tests. Int J STD AIDS. 2009;20(11):752-753.

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Footnote 25

25.McCormack WM, Stumacher RJ, Johnson K, Donner A. Clinical spectrum of gonococcal infection in women. Lancet. 1977;1(8023):1182-1185.

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Footnote 26

26.Chan PA, Robinette A, Montgomery M, et al. Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature. Infect Dis Obstet Gynecol. 2016;2016:5758387. doi:10.1155/2016/5758387

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Footnote 27

27.Jin F, Prestage GP, Zablotska I, et al. High rates of sexually transmitted infections in HIV positive homosexual men: data from two community based cohorts. Sex Transm Infect. 2007; 83(5):397-399.

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Footnote 28

28.Dukers-Muijrers NH, Schachter J, van Liere GA, Wolffs PF, Hoebe CJ. What is needed to guide testing for anorectal and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae in women and men? Evidence and opinion. BMC Infect Dis. 2015;15:533. Published 2015 Nov 17. doi:10.1186/s12879-015-1280-6

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