ORIGINAL STUDY
Gonococcal Conjunctivitis in Adults: Case Report
and Retrospective Review of Cases in Alberta, Canada,
2000–2016
Sara Belga, MD,* Jennifer Gratrix, MSc,† Petra Smyczek, MD,*†‡ Lindsay Bertholet, MN,†
Ron Read, MD, PhD,§ Kelsey Roelofs, MD,* and Ameeta E. Singh, BMBS, MSc*‡
Downloaded from https://journals.lww.com/stdjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FJPxKcC74DHjQXXsmGyC33wtk6pznWVOyPFAw9JJsKA= on 06/08/2020
Background: A case of gonococcal conjunctivitis (GC) prompted us to
review the reported cases and treatment regimens of GC in Alberta, Canada.
Methods: Gonococcal cases reported from 2000 to 2016 were extracted
from the provincial sexually transmitted infection reporting database. The
diagnosis of GC was based on a positive culture and/or nucleic acid ampli-
fication test from the eye.
Results: A total of 45 cases of GC were reported in adults. Three quarters
(75.6%; n = 34) of the cases were diagnosed using culture, 57.8% (n = 26)
of cases were among men, and 55.5% (n = 25) were diagnosed since 2014.
Very few (13.3%; n = 6) of the cases were treated according to current
Canadian Guidelines on Sexually Transmitted Infections, using 2 g of
ceftriaxone in combination with azithromycin or doxycycline. Results of
test of cures were available for 15.6% (n = 7) of the cases and occurred
within 10 to 79 days (median = 26 days) after treatment; all were negative.
Conclusions: Gonococcal conjunctivitis was relatively uncommon in our
region, but given its potential for severe manifestations and sequelae
coupled with the rising rates of gonorrhea; it remains important to consider
this diagnosis in sexually active individuals presenting with purulent con-
junctivitis. Additional studies are needed to inform treatment recommenda-
tions and to evaluate outcomes of infection.
G onococcal conjunctivitis (GC) is caused by the gram negative
diplococcus Neisseria gonorrhoeae (NG) and is part of the
spectrum of extra-genital gonococcal infections. Gonococcal con-
junctivitis affects 2 main groups, neonates where this entity is
called ophthalmia neonatorum, and sexually active persons.1 Gon-
ococcal ophthalmia neonatorum is acquired from an infected
mother during delivery, and occurs in 30% to 50% of neonates ex-
posed perinatally.2 In non-neonates, infections result from auto-
inoculation or inoculation of infected genital secretions from a
sexual partner.3 However, GC in both neonates and adults is rela-
tively rare in the industrialized world.1–3
The onset of GC is hyperacute and is characterized by
chemosis and profuse purulent discharge.4 Symptoms can be rap-
idly progressive and ocular consequences can be devastating, due
to the ability of NG to penetrate intact corneal epithelium.5 The
clinical spectrum of this infection can vary greatly, with some
cases presenting with isolated purulent conjunctivitis while others
also involve the cornea. The degree of corneal involvement in gon-
ococcal infection of the eye can also vary significantly, ranging
From the *University of Alberta, Edmonton; †STI Centralized Services,
Alberta Health Services, Alberta; ‡Edmonton STI Clinic, Alberta
Health Services, Edmonton; and §Calgary STI Clinic, Alberta Health
Services, Calgary, Canada
Conflicts of Interest and Sources of Funding: None declared.
Correspondence: Ameeta E. Singh, BMBS, MSc 3B20 11111-Jasper Ave
Edmonton, AB, Canada T5K0L4. E‐mail: ameeta@ualberta.ca.
Received for publication May 2, 2018, and accepted July 15, 2018.
DOI: 10.1097/OLQ.0000000000000897
Copyright © 2018 American Sexually Transmitted Diseases Association
All rights reserved.
Sexually Transmitted Diseases • Volume 46, Number 1, January 2019
Copyright © 2018 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
from subepithelial and/or stromal infiltrates to corneal ulceration
with subsequent thinning and perforation of the globe, resulting
in endophthalmitis.4 Corneal involvement in these cases is of par-
ticular concern, because it can often lead to significant visual im-
pairment. In the periorbital region, GC can cause significant lid
edema which can mimic preseptal cellulitis.6 Occasionally, swell-
ing may be severe enough to cause limitation of extraocular move-
ments, which may lead to the misdiagnosis of orbital cellulitis.
Because of the subtlety or lack of significant genitourinary (GU)
symptoms, the diagnosis can often be delayed7; however, expedi-
tious diagnosis and treatment is key in attempting to limit corneal
involvement and, ultimately, in achieving preservation of vision.1
Throughout the study period, the Canadian treatment
guidelines for GC recommended ceftriaxone 2 g/d intravenous/
intramuscular PLUS doxycycline/azithromycin while awaiting
consultation.
The rate of gonorrhea in Alberta, Canada, has been increas-
ing steadily from a low of 19/100,000 in 2000 to a peak of 87/
100,000 in the midst of a provincial outbreak in 2016 (Fig. 1).8
Data on the frequency and outcomes of GC are limited. We sought
to retrospectively evaluate the number and characteristics of re-
ported cases, the treatment regimens, and outcomes of GC in
Alberta, Canada, after a patient presented to our hospital with
this condition.
CASE REPORT
A previously healthy 21-year-old woman presented to the
emergency department (ED) with a 1-day history of left upper
eyelid swelling, conjunctival injection, and profuse purulent dis-
charge. Her visual acuity was unchanged, and she was discharged
from the ED on oral cephalexin and topical erythromycin,
tobramycin, and dexamethasone. An ocular swab was sent for
culture and NG and Chlamydia trachomatis (CT) nucleic acid
amplification testing (NAAT) using the GenProbe Aptima
Combo 2 Assay (Hologic Inc, USA). Three days later, she re-
presented with increasing ocular pain from her left eye. Urgent
assessment by ophthalmology noted clinical findings of bacte-
rial conjunctivitis. Her visual acuity was normal in her right eye
(OD 20/20) but moderately decreased in her left eye (20/50).
There was no significant corneal thinning or infiltrate. No sys-
temic or GU symptoms were present. When the eye specimen
NAAT result returned positive for NG the following day, the pa-
tient was admitted to hospital and treated with ceftriaxone 2 g
intravenously (IV) single dose followed by 1 g IV daily for 4 ad-
ditional days and azithromycin 2 g orally single dose and doxycy-
cline 100 mg orally twice daily for 7 days; the latter was given as
per ophthalmology protocol for the prevention of corneal melt.9
She also underwent frequent conjunctival lavage. Urine was also
positive for NG NAAT. Human immunodeficiency virus (HIV)
antibody was negative. The patient reported 3 male partners in
the preceding 6 months with a new partner in the month before
the current presentation.
47
Belga et al.
Figure 1. Gonorrhea incidence rate per 100,000 population and rate of conjunctivitis per 100 gonorrhea cases (Alberta, 2000–2016).
Following discharge from the hospital, she was seen in fol-
low up; her visual acuity had returned to baseline (20/20 in both
eyes) and there were no signs of permanent ocular sequelae.
Retrospective Review of Alberta Cases
METHODS
Gonorrhea is a notifiable disease in both Canada and the
province of Alberta. As part of the notifiable disease reporting
guidelines, all gonorrhea cases are reported to the provincial Sex-
ually Transmitted Infection (STI) Services. Testing providers
complete a notification form which includes information on de-
mographics, exposure risks and recent sexual partners. GC cases
among adults (≥12 years) reported in Alberta from 2000 to 2016
were extracted from the provincial STI reporting database. The
diagnosis of GC was based on a positive culture and/or NAAT re-
sult from the eye.
The data extract included date of diagnosis, sex, age, eth-
nicity, sexual partners, STI and HIV co-infection, testing provider,
treatment, and additional anatomical sites that were infected. Test-
ing provider was categorized as acute care, community provider,
or a provincial STI clinic. For culture-positive isolates, minimum
inhibitory concentrations (MIC) were provided for cefixime, cef-
triaxone, ciprofloxacin, azithromycin, penicillin, and tetracycline
using E-test conducted by the Alberta Provincial Laboratory of
Public Health.
The molecular genotyping of the N. gonorrhoeae isolates
using the Neisseria gonorrhoeae multi-antigen sequence typing
(NG-MAST) method incorporated the amplification of the porin
gene (por) and the transferrin-binding protein gene (tbpB) as previ-
ously described.10 The resulting polymerase chain reaction products
were purified (QIA Quick PCR Purification Kit, Qiagen, Missis-
sauga, Ontario or Agencourt AMPure, Beckman Coulter, Beverly,
MA), and the DNA sequences of both strands obtained by the
DNA Analyzer 3730xl (Applied Biosystems, Foster City, CA) were
edited, assembled, and compared using software from DNAStar,
Inc. (Madison, WI). The resulting sequences were submitted to the
NG-MAST Web site (http://www.ng-mast.net/) to determine the STs.
Treatment data was divided into 5 categories based on
the treatment containing at least: ceftriaxone 2 g IV, ceftriaxone
250 mg to 1 g IV, cefixime 800 mg orally, ciprofloxacin 500 mg
orally, and other. Provincial treatment guidelines recommended
all patients with extra-genital sites should have a test of cure (TOC).
48 Sexually Transmitted Diseases
Copyright © 2018 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
TOC with culture may be collected 3 days posttreatment and those
collected using molecular testing 2–3 weeks after treatment. Sexu-
ally transmitted infection clinic charts were reviewed by an infec-
tious disease physician to complete missing variables and retrieve
information on TOC.
Descriptive analysis of GC patients by sex were compared
using Chi-square or Fisher’s exact for discrete variables and
Mann-Whitney for age, using IBM SPSS Statistics version 19.0
(IBM, Armonk, NY, USA). Ethics approval was obtained from
the University of Alberta’s Health Research Ethics Board.
RESULTS
Forty-five GC cases were reported between 2000 and 2016.
Over one half (55.5%; n = 25) of the cases were reported between
2014 and 2016. The rate of GC cases has ranged between 0 and
0.3 cases per 100 NG cases with the proportion of cases increas-
ing with incidence rate increases (Fig. 2). One quarter of cases
(26.7%; n = 12) also had GU infections.
Nearly 60% (n = 26) of cases were among men; however,
there were no significant differences between sexes for ethnicity,
geographic area of diagnosis, sexual partner, test type, HIV status,
minimum treatment, or test of cure (Table 1). Women were youn-
ger at the time of diagnosis (median age, 21 years vs. 31 years;
P = 0.03) and more likely to be diagnosed in an acute care facility
(3.7% vs. 42.3%; P = 0.04) than men.
The majority (75.6%; n = 34) of cases were diagnosed using
culture, with the majority (88.2%; n = 30) being culture-only. All
isolates with available MIC data were susceptible to azithromycin
(n = 30, <2 mg/L), cefixime (n = 30, <0.5 mg/L), and ceftriaxone
Figure 2. A case of GC with profuse purulent discharge and chemosis.
• Volume 46, Number 1, January 2019
 Gonococcal Conjunctivitis in Adults

TABLE 1. Description of Gonococcal Conjunctivitis Cases by Sex (Alberta, 2000–2016; N = 45)

n (%) Female (n = 19) Male (n = 26) Total (n = 45) P
Median age (IQR) 21 (17–32) 31 (21–40) 24 (20–33) 0.03
Ethnicity
White 3 (15.8) 10 (38.5) 13 (28.9) 0.36
First nations 8 (42.1) 7 (26.9) 15 (33.3)
Other 1 (5.3) 2 (7.7) 3 (6.7)
Unknown 7 (36.8) 7 (26.9) 14 (31.1)
Geographic area
Calgary 4 (21.1) 8 (30.8) 12 (26.7) 0.57
Edmonton 14 (73.7) 15 (57.7) 29 (64.4)
Other 1 (5.3) 3 (11.5) 4 (8.9)
Sexual partner
Bisexual 1 (5.3) 1 (3.8) 2 (4.4) 0.09
Opposite sex 13 (68.4) 12 (46.2) 25 (55.6)
Same sex 0 6 (23.1) 6 (13.3)
Unknown 5 (26.3) 7 (26.9) 12 (26.7)
Test type
Culture-only 14 (73.7) 16 (61.5) 30 (66.7) 0.12
Culture and NAAT 3 (15.8) 1 (3.8) 4 (8.9)
NAAT only 2 (10.5) 9 (34.6) 11 (24.4)
HIV status
Negative 13 (68.4) 20 (76.9) 33 (73.3) 0.35
Positive 2 (10.5) 0 2 (4.4)
Unknown 4 (21.1) 6 (23.1) 10 (22.2)
Testing provider
Acute care 14 (73.7) 11 (42.3) 25 (55.6) 0.04
Community provider 5 (26.3) 9 (34.6) 14 (31.1)
STI clinic 0 6 (23.1) 6 (13.3)
Minimum treatment*
Ceftriaxone 2 g IV SD 2 (11.1) 6 (25.0) 8 (19.0) 0.67
Ceftriaxone <2 g IV SD 10 (55.6) 10 (41.7) 20 (47.6)
Cefixime 800 mg orally SD 1 (5.6) 3 (12.5) 4 (9.5)
Ciprofloxacin 500 mg orally SD 2 (11.1) 3 (12.5) 4 (9.5)
Other† 3 (16.7.1) 2 (8.3) 5 (11.9)
Test of cure 2 (10.5) 5 (19.2) 7 (15.6) 0.68

*Treatment data was available for 42 cases.

†Cephalexin, cefixime at dose other than 800 mg/d, azithromycin, erythromycin, tobramycin.
IV, intravenous; SD, single dose; NAAT, nucleic acid amplification test.

(n = 28, <0.5 mg/L). A small number of isolates (16.7%; n = 5)
were ciprofloxacin-resistant (≥1.0 mg/L), penicillin-resistant (13.3%;
n = 4; ≥2.0 mg/L), and tetracycline-resistant (16.7%; n = 5;
≥2.0 mg/L). The NG-MAST sequence typing was available for
5 isolates collected between 2014 and 2015, and all were unique
and previously reported in the province (ST-5, resistant to ciproflox-
acin, penicillin, and tetracycline; ST-3935, tetracycline resistant;
ST-5985, tetracycline resistant; ST-10451, resistant to ciprofloxa-
cin, penicillin, erythromycin, and tetracycline; and ST-12122, resis-
tant to penicillin, erythromycin, and tetracycline).
Treatment information was available for 93.3% (n = 42) of
the cases. Of the cases where treatment date was available (n = 40),
55.0% (n = 22) were treated on the same day as the first specimen
was collected. The remaining cases (n = 18) were treated within 1
to 30 days. Of the 42 cases with treatment records, 8 (19.0%) of
the cases were treated with a regime containing ceftriaxone 2 g
between 2008 and 2015, and only 6 (14.3%) of these cases met
Canadian treatment guidelines with concomitant use of azithromycin
or doxycycline. Nearly one half (47.6%; n = 20) of the cases were
treated with a treatment containing ceftriaxone between 125 mg and
1 g, with use beginning in 2004 and continuing into 2016. Five
(11.9%) cases were treated with a regime containing 500 mg of cip-
rofloxacin, all were treated between 2003 and 2007. Four (9.5%)
cases were treated with a regime containing cefixime 800 mg;
2 cases in both 2015 and 2016. The remaining 5 (11.9%) cases
were treated with other drugs, throughout the period. There was
no significant difference between drug regimen and provider
type (P = 0.81).
Results of TOC were available for 15.6% (n = 7) of the
cases and occurred within 10 to 79 days (median, 26 days; IQR,
14–47 days) after treatment, all were negative. We excluded 2
cases in which TOC was only done at 102 and 229 days posttreat-
ment. Cases with a TOC occurred between 2008 and 2016. The
majority (71.4%; n = 5) of TOC cases were diagnosed at an acute
care facility, with an additional case diagnosed each at a commu-
nity providers and a STI Clinic. TOC cases were treated at base-
line with ceftriaxone, 2 g (42.9%; n = 3); ceftriaxone, less than
2 g (42.9%; n = 3); and cefixime, 800 mg (14.3%; n = 1).
DISCUSSION
Our case report and case series highlight the importance
of GC and the need for a high index of suspicion, especially
when a patient presents with hyperacute conjunctivitis with sig-
nificant chemosis and purulence (Fig. 2 shows the right eye of a
patient with a similar presentation to our patient as a photograph
of our patient was not available). Unfortunately, cases of GC may
present with less typical findings, such as lid edema, which may
mimic periorbital cellulitis, and is more likely to result in delays
in diagnosis.6 The diagnosis may be further delayed by the subtlety
or absence of significant GU symptoms.7
In our case report, despite the delay in diagnosis and treat-
ment, the final outcome was excellent with normalization of visual

Sexually Transmitted Diseases • Volume 46, Number 1, January 2019 49

Copyright © 2018 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Belga et al.
acuity and no evidence of ocular abnormalities after appropriate
treatment. Our decision to prolong treatment with ceftriaxone
was based on the potential for corneal involvement and uncer-
tainty of adherence to close follow-up and may have contributed
to the successful outcome because gonococcal keratoconjunctivi-
tis can progress rapidly to corneal destruction, endophthalmitis,
and visual loss.4
Very few studies have reported on the outcomes of cases of
GC,11,12 our study provides one of the largest retrospective re-
views in the medical literature. More than half of cases in our
study were reported between 2014 and 2016, which may in part re-
flect the preferred use of highly sensitive NAAT tests to screen for
gonorrhea instead of culture since 2014. In addition, reported gon-
orrhea rates have risen significantly in Alberta during the study pe-
riod from 2015 to 2016. However, the fact that nearly 70% of the
cases were diagnosed by culture contradicts NAAT as the main
driver for the increase in GC cases in recent years.
Although the recommended treatment for gonococcal in-
fection of the eye has not changed, the treatment for urogenital
gonorrhea in Canada has changed over time as follows: (i) 2000
to 2006, ciprofloxacin 500 mg orally single dose; (ii) 2006 to
2011, cefixime 400 mg orally as a single dose; and (iii) 2011 to
2018, ceftriaxone in addition to azithromycin 1 g orally in a single
dose.13–15 Overall, of the 42 cases with treatment data available,
only a small proportion of cases received guideline-concordant
treatment with less than 20% treated with the recommended dose
of ceftriaxone (2 g IV/IM) and only 14% having received it in
combination with azithromycin or doxycycline, as recommended
by the Canadian STI guidelines. Dual therapy is intended to po-
tentially reduce the emergence and spread of NG resistance to
cephalosporins and to potentially enhance treatment efficacy as
supported by recent evidence.13,16 Dual therapy in GC is partic-
ularly important considering that tissue penetration may consti-
tute another barrier to successful treatment.
Expeditious diagnosis and treatment are key in attempting
to limit corneal involvement and preserve vision.1 Across the
globe, variable recommendations for first-line therapy exist and
include intravenous or intramuscular ceftriaxone with or without
azithromycin13,17–21 (Table 2). Treatment duration varies from 1
to 3 days, but advice is not provided about altering treatment dose
or duration based on the severity of eye involvement.13,17–21
European,19 United Kingdom18 and New Zealand17 guidelines
support more prolonged courses of ceftriaxone given the rela-
tively avascular nature of the cornea.
In our case series, most cases were diagnosed in acute care
facilities followed by community-based practices and a small per-
centage in STI clinics. Despite the guideline recommendations to
collect a TOC in extragenital sites, only 15.6% of our patients
had follow-up NG testing done. Although patient compliance
TABLE 2. Global Guidelines for the Treatment of Gonococcal
Conjunctivitis in Adults/Adolescents
Current Guidelines Treatment (Preferred)
European 201219 Ceftriaxone 500 mg IM daily for 3 d
United Kingdom 201118 Ceftriaxone 500 mg IM daily for 3 d
Australia 201721 Ceftriaxone 500 mg IM single dose and
Azithromycin 1 g PO single dose
New Zealand 201417 Ceftriaxone 500 mg IM daily for 3 d
US (CDC) 201520 Ceftriaxone 1 g IM single dose and
Azithromycin 1 g po single dose
Canada (PHAC) 2013 Ceftriaxone 2 g IV/IM single dose
and Azithromycin 1 g single dose
IM, intramuscular; IV, intravenous; PO, per os; CDC, Centers for Dis-
ease Control and Prevention; PHAC, Public Health Agency of Canada.
50 Sexually Transmitted Diseases
Copyright © 2018 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
could have played a role, clinician knowledge of our current
guidelines is likely suboptimal. These findings highlight the need
to enhance awareness of treatment and TOC recommendations by
clinicians outside of STI clinics, where most cases will likely be
seen.11 Some of the variation in the prescribed regimen may be re-
lated to the lack of consistency across global guidelines (Table 2).
Although GC without concurrent GU infection has been re-
ported,22,23 the approximately one quarter of cases in our sample
with concurrent NG in the GU tract is probably an underestimate,
as we were unable to confirm if all individuals were screened from
the genital tract.
Our study is not without limitations. Its retrospective nature
and small size provided limited statistical power to compare treat-
ment regimens. As well, clinical indications for choosing treat-
ment regimens were not available, and therefore, we are not able
to rule out any bias this may have introduced. Treatment data are
limited to records submitted to public health, and it is possible
other treatments were received by the patient after reporting oc-
curred. We did not have access to testing data to determine the pro-
portion of patients with GC that were tested from other anatomical
sites; it would have been relevant to know which patients were
tested from anogenital and pharyngeal sites as GC most com-
monly results from auto-inoculation. Finally, information on visual
outcomes, particularly degree of ocular involvement, need for sur-
gery, and post-GC visual acuity, is not required by our reporting
program and was not available for review.
Although GC has become relatively uncommon in the in-
dustrialized world, the rising rates of gonorrhea in many regions
of the world make it an important consideration in sexually-
active individuals presenting with purulent conjunctivitis. Cur-
rent treatment duration recommendations for GC are based on
very limited evidence, and this is reflected in the considerable
variation in recommendations across international guidelines.13,17–21
Also, the spectrum of GC severity has not been addressed in the
guidelines as most data comes from case series and reports.1,6,7,23–30
Our study has identified the need for further studies of treat-
ment and outcomes of GC, especially to determine if higher
or longer doses of antibiotics are required with more severe
disease presentations.
REFERENCES
1. Lee JS, Choi HY, Lee JE, et al. Gonococcal keratoconjunctivitis in
adults. Eye (Lond) 2002; 16:646–649.
2. Moore DL, MacDonald NE. Canadian Paediatric Society ID, immuni-
zation C. Preventing ophthalmia neonatorum. Paediatr Child Health
2015; 20:93–96.
3. Saad N, Francis IC, Kappagoda MB, et al. Adult penicillinase-producing
gonococcal keratoconjunctivitis. Med J Aust 1988; 149:710–711.
4. Wan WL, Farkas GC, May WN, et al. The clinical characteristics and
course of adult gonococcal conjunctivitis. Am J Ophthalmol 1986;
102:575–583.
5. Duke-Elder S. Diseases of the outer eye. In: Duke-Elder S, ed. System
of Ophthalmology VIII, part 1. St Louis: CV Mosby, 1966:162–174.
6. Hegde V, Smith G, Choi J, et al. A case of gonococcal kerato-
conjunctivitis mimicking orbital cellulitis. Acta Ophthalmol Scand
2005; 83:511–512.
7. Guerrero ML, Alfaro IJ, Sandoval BG, et al. “Ophthalmia Venerea”:
A dreadful complication of fluoroquinolone-resistant Neisseria
gonorrhoeae. Sex Transm Dis 2010; 37:340–341.
8. Alberta Health. Interactive Health Data Application. [Available from:
http://www.ahw.gov.ab.ca/IHDA_Retrieval/redirectToURL.do?cat=
81&subCat=466.
9. McElvanney AM. Doxycycline in the management of pseudomonas
corneal melting: Two case reports and a review of the literature.
Eye Contact Lens 2003; 29:258–261.
• Volume 46, Number 1, January 2019

10. Martin IM, Ison CA, Aanensen DM, et al. Rapid sequence-based iden-
tification of gonococcal transmission clusters in a large metropolitan
area. J Infect Dis 2004; 189:1497–1505.
11. McAnena L, Knowles SJ, Curry A, et al. Prevalence of gonococ-
cal conjunctivitis in adults and neonates. Eye (Lond) 2015; 29:
875–880.
12. Quirke M, Cullinane A. Recent trends in chlamydial and gonococcal
conjunctivitis among neonates and adults in an Irish hospital. Int J In-
fect Dis 2008; 12:371–373.
13. Section 5-6: Canadian Guidelines on Sexually Transmitted Infections—
Management and treatment of specific infections—gonococcal infec-
tions. Public Health Agency of Canada; July 2013 [Available from:
https://www.canada.ca/en/public-health/services/infectious-diseases/
sexual-health-sexually-transmitted-infections/canadian-guidelines/
sexually-transmitted-infections/canadian-guidelines-sexually-
transmitted-infections-34.html.
14. Canadian Guidelines on Sexually Transmitted Infections 2016
Updates Summary. Public Health Agency of Canada; April 2017
[Available from: https://www.canada.ca/en/public-health/services/
infectious-diseases/sexual-health-sexually-transmitted-infections/
canadian-guidelines/2016-updates-summary.html - a2.1.
15. Revised version of the Canadian Sexually Transmitted Infections
Guidelines—2006 edition 2008 [Available from: http://publications.
gc.ca/collections/collection_2011/aspc-phac/HP40-1-2010-eng.pdf.
16. Singh V, Bala M, Bhargava A, et al. In vitro efficacy of 21 dual antimi-
crobial combinations comprising novel and currently recommended
combinations for treatment of drug resistant gonorrhoea in future era.
PLoS One 2018; 13:e0193678.
17. Gonorrhoea Guideline Writing Group NZSHS. New Zealand Guideline
for the Management of Gonorrhoea September 2014 [Available from:
http://www.nzshs.org/docman/guidelines/best-practice-guidelines/142-
new-zealand-guideline-for-the-management-of-gonorrhoea-2014-and-
response-to-the-threat-of-antimicrobial-resistance/file.
Sexually Transmitted Diseases • Volume 46, Number 1, January 2019
Copyright © 2018 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Gonococcal Conjunctivitis in Adults
18. Bignell C, Fitzgerald M, Guideline Development G, British Associa-
tion for Sexual H, HIV UK. UK national guideline for the management
of gonorrhoea in adults, 2011. Int J STD AIDS 2011; 22:541–547.
19. Bignell C, Unemo M, European STIGEB. 2012 European guideline on
the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS
2013; 24:85–92.
20. CDC. Sexually transmitted diseases treatment guidelines. MMWR
Recomm Rep 2015; 64: (No. RR-3).
21. ASHA. Australian STI Management Guidelines For Use in Primary
Care December 2017 [Available from: http://www.sti.guidelines.org.
au/sexually-transmissible-infections/gonorrhoea-management.
22. Harry TC, Black PD. Unilateral gonococcal ophthalmia without geni-
tal infection: An unusual presentation in an adult. Int J STD AIDS
2005; 16:78–79.
23. Annan NT, Boag FC. Outpatient management of severe gonococcal oph-
thalmia without genital infection. Int J STD AIDS 2008; 19:573–574.
24. McElnea E, Stapleton P, Khan S, et al. Challenges in the management
of Neisseria gonorrhoeae keratitis. Int Ophthalmol 2015; 35:135–140.
25. Day AC, Ramkissoon YD, George S, et al. Don't forget gonococcus!
Eye (Lond) 2006; 20:1400–1402.
26. Haimovici R, Roussel TJ. Treatment of gonococcal conjunctivitis with
single-dose intramuscular ceftriaxone. Am J Ophthalmol 1989; 107:
511–514.
27. Haase DA, Nash RA, Nsanze H, et al. Single-dose ceftriaxone therapy of
gonococcal ophthalmia neonatorum. Sex Transm Dis 1986; 13:53–55.
28. Kumar P. Gonorrhoea presenting as red eye: Rare case. Indian J Sex
Transm Dis 2012; 33:47–48.
29. Pellerano RA, Bishop V, Silber TJ. Gonococcal conjunctivitis in ado-
lescents. Recognition and management. Clin Pediatr (Phila) 1994; 33:
114–116.
30. Bodurtha Smith AJ, Holzman SB, Manesh RS, et al. Gonococcal con-
junctivitis: A case report of an unusual mode of transmission. J Pediatr
Adolesc Gynecol 2017; 30:501–502.
51