Gonococcal infection: clinical guidelines

List of Abbreviations

HIV - human immunodeficiency virus

DNA - deoxyribonucleic acid

STI — sexually transmitted infection

ICD — International Classification of Diseases

PCR — polymerase chain reaction

RNA - ribonucleic acid

NASBA (Nucleic Acids Sequence-Based Amplification) - transcription-based

amplification reaction

Terms and Definitions

Gonococcal infection is a human sexually transmitted infection caused by gonococci (Neisseria gonorrhoeae).

Neisseria gonorrhoeae are Gram-negative diplococci, which are kidney-bean-shaped, non-motile, non-spore-forming, pyogenic bacteria.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Gonococcal infection is a sexually transmitted infection caused by Neisseria gonorrhoeae - Gram-negative diplococci, which are kidney-bean-shaped, non-motile, non-spore-forming, pyogenic bacteria.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The causative agent of gonococcal infection is a Gram-negative kidney-bean-shaped diplococcus belonging to the family Neisseriaceae, genus Neisseria, species Neisseria gonorrhoeae. The length of the gonococcus ranges from 1.25 to 1.6 µm, and the transverse diameter ranges from 0.7 to 0.8 µm. Gonococci are surrounded by a capsule-like structure, preventing them from contacting one another. Scanning electron microscopy reveals that gonococci possess pili - thin filaments responsible for virulence properties and the transfer of genetic information - as well as bulbous swellings associated with the outer wall. Gonococci are capable of transitioning from a non-piliated to a piliated state and vice versa, depending on pilus gene expression, which is regulated by various types of gonococcal proteins. The tri-layered outer membrane of gonococci contains several classes of proteins, including protein I (gonococci with protein IA are more commonly associated with disseminated gonococcal infection, whereas those with protein IB are associated with antibacterial drug resistance), protein II (which promotes enhanced adhesion of gonococci to each other and to various types of epithelial cells, but is not constitutively expressed; in its absence, gonococci form "transparent" colonies that are more frequently found in disseminated gonococcal infection and associated with increased resistance to normal human blood serum), and protein III (which reduces the bactericidal activity of blood serum through the expression of blocking antibodies).

Examination of ultra-thin sections of the gonococcus also reveals the cytoplasmic membrane and tri-layered cytoplasm with small granular formations - ribosomes - suspended in it, along with a nuclear vacuole. A septum is identified between the diplococci, and a loop-like mesosome connected to the plasma membrane can sometimes be distinguished near it. These structures are located at the sites of the microorganism's most active growth.

Gonococci firmly attach to mucosal epithelial cells using pili and localized areas of protein II, reaching the subepithelial connective tissue through intercellular spaces and eliciting an inflammatory reaction with the release of purulent exudate containing gonococci. The causative agent of gonococcal infection affects the columnar epithelial cells of the urethra and cervical canal (in girls and menopausal women, involvement of vaginal epithelial cells is possible), spreading contiguously (per continuitatem) along the urogenital mucosa or via lymphatic vessels to more distant parts of the urogenital tract: the posterior urethra, prostate gland, seminal vesicles, epididymides, fallopian tubes, ovaries, etc. Retrograde spread of gonococci into the uterine cavity or epididymis via antiperistaltic movements of the uterus or vas deferens is also possible. In extragenital forms of the disease, involvement of the oropharyngeal, rectal, and conjunctival mucosa may occur. Hematogenous dissemination of gonococci with transient gonococcemia or gonococcal sepsis, manifesting as gonococcal septicemia and septicopyemia, is occasionally observed.

Gonococcal infection leads to the development of infiltrative and degenerative processes in the mucous membranes of the urogenital and reproductive systems, rectum, oropharynx, and conjunctiva. In the chronic course of the disease, along with exudative changes, proliferative changes are identified: inflammatory infiltrates in the subepithelial layer become focal, the columnar epithelium in certain areas transforms into stratified squamous epithelium, frequently with keratinization, the outcome of which may be cicatricial tissue atrophy.

Infection in adults occurs through any form of sexual contact with a person suffering from gonococcal infection; in children, through perinatal transmission and sexual contact; in exceptional cases, young girls may become infected due to breaches in personal hygiene and childcare practices.

1.3 Epidemiology of the Disease or Condition

Gonococcal infection is one of the most common sexually transmitted infections (STIs). According to World Health Organization estimates, approximately 60 million cases of the disease are registered worldwide each year.

In the Russian Federation, incidence rates of gonococcal infection have declined in recent years, yet they remain quite high - in 2022, the incidence rate was 8.1 per 100,000 population.

1.4 Features of Coding the Disease or Condition

A54 Gonococcal infection:

A54.0 - Gonococcal infection of the lower genitourinary tract without abscessation of periurethral and accessory glands.

(Gonococcal: cervicitis, cystitis, urethritis, vulvovaginitis)

A54.1 - Gonococcal infection of the lower genitourinary tract with abscessation of periurethral and accessory glands.

(Gonococcal abscess of greater vestibular glands)

A54.2+ - Gonococcal pelvioperitonitis and other urogenital gonococcal infections.

Gonococcal: epididymitis (N51.1), orchitis (N51.1), prostatitis (N51.0), female pelvic inflammatory disease (N74.3);

A54.3 - Gonococcal eye infection.

Gonococcal: conjunctivitis+ (H13.1), iridocyclitis (H22.0), neonatal gonococcal ophthalmia;

A54.4 - Gonococcal infection of the musculoskeletal system.

Gonococcal: arthritis (M01.3), bursitis (M73.0), osteomyelitis (M90.2), synovitis (M68.0), tenosynovitis (M68.0);

A54.5 - Gonococcal pharyngitis;

A54.6 - Gonococcal infection of the anorectal region;

A54.8 - Other gonococcal infections.

Gonococcal: brain abscess (G07), endocarditis (I39.8), meningitis (G01), myocarditis (I41.0), pericarditis (I32.0), peritonitis (K67.1), pneumonia (J17.0), sepsis, skin lesion;

A54.9 - Gonococcal infection, unspecified.

1.5 Classification of the disease or condition

The clinical classification of gonococcal infection is based on the localization of the pathological process.

1. Gonococcal infection of the lower genitourinary tract without abscess formation in periurethral and accessory glands:

1.1 urethritis;

1.2 cervicitis;

1.3 cystitis;

1.4 vulvovaginitis.

2. Gonococcal infection of the lower genitourinary tract with abscess formation in periurethral and accessory glands.

2.1 abscess of greater vestibular gland;

2.2 periurethritis;

2.3 vestibulitis.

3. Gonococcal pelvioperitonitis and other gonococcal genitourinary infections:

3.1 epididymitis;

3.2 orchitis;

3.3 prostatitis;

3.4 salpingo-ooophoritis;

3.5 endometritis;

3.6 pelvioperitonitis.

4. Gonococcal eye infection:

4.1 conjunctivitis;

4.2 iridocyclitis;

4.3 neonatal ophthalmia.

5. Gonococcal musculoskeletal infection:

5.1 arthritis;

5.2 bursitis;

5.3 osteomyelitis;

5.4 synovitis;

5.5 tenosynovitis.

6. Gonococcal pharyngitis.

7. Gonococcal infection of the anorectal region.

8. Other gonococcal infections:

8.1 brain abscess;

8.2 endocarditis;

8.3 meningitis;

8.4 myocarditis;

8.5 pericarditis;

8.6 pneumonia;

8.7 sepsis;

8.8 skin lesion.

1.6 Clinical presentation of the disease or condition

Gonococcal infection of the lower genitourinary tract without abscess formation in periurethral and accessory glands.

More than 70% of women have a subjectively asymptomatic course of the disease. In the presence of clinical manifestations, the following subjective symptoms in women may occur: purulent or mucopurulent discharge from the urethra and/or genital tract; itching, burning in the external genitalia; pain during sexual intercourse (dyspareunia); itching, burning, pain during urination (dysuria); discomfort or pain in the lower abdomen.

Objective symptoms of the disease in women include: hyperemia and edema of the mucosa of the external urethral orifice, infiltration of the urethral walls, mucopurulent or purulent urethral discharge; hyperemia and edema of the vulvar and vaginal mucosa; mucopurulent or purulent discharge in the posterior and lateral vaginal fornices; edema, hyperemia, and erosion of the cervical mucosa, mucopurulent or purulent discharge from the cervical canal.

Subjective symptoms of gonococcal infection in men include: purulent urethral discharge; itching, burning, pain during urination (dysuria); itching, burning in the urethra area; pain during sexual intercourse (dyspareunia); frequent urination and urinary urgency (with proximal spread of the inflammatory process); pain in the perineum radiating to the rectum.

Objective symptoms of the disease in men include: hyperemia and edema of the mucosa of the external urethral orifice, infiltration of the urethral walls, purulent urethral discharge.

Gonococcal infection of the lower genitourinary tract with abscess formation in periurethral and accessory glands.

Subjective symptoms of vestibulitis include: mild purulent or mucopurulent discharge from the genital tract; pain and swelling in the vulvar region. When a glandular abscess forms, symptoms of general intoxication join; pain increases with walking and at rest, acquiring a throbbing character.

Objective symptoms of vestibulitis include: hyperemia of the external openings of the vestibular gland ducts; mild purulent or mucopurulent discharge from the genital tract; pain and swelling in the area of the vestibular gland ducts upon palpation. When a glandular abscess forms - general and local hyperthermia, mucopurulent or purulent discharge is observed upon palpation of the gland; clearly demarcated infiltration, hyperemia, and pronounced pain in the duct projection zone are determined

In individuals of both sexes, gonococcal involvement of the periurethral glands is possible, with the subjective symptoms being: itching, burning, pain during urination (dysuria); purulent or mucopurulent urethral discharge; pain during sexual intercourse (dyspareunia); pain in the area of the external urethral orifice; objective symptoms of periurethritis include: purulent or mucopurulent urethral discharge; presence of dense, painful millet-sized formations in the area of the excretory ducts of the periurethral glands.

Gonococcal infection of the anorectal region

In individuals of both sexes, a subjectively asymptomatic course of the disease is generally noted. In the presence of clinical manifestations, the following subjective symptoms may occur: with localized rectal involvement: itching, burning in the anorectal region, scanty yellowish or reddish rectal discharge; with localization of the process above the anal opening: painful tenesmus, pain during defecation, mucopurulent rectal discharge, often mixed with blood, secondary constipation.

Objective symptoms in individuals of both sexes include: hyperemia of the skin of the anal folds; mucopurulent or purulent discharge from the rectum.

Gonococcal pharyngitis

In individuals of both sexes, a subjectively asymptomatic course of the disease is generally noted. In the presence of clinical manifestations, the following subjective symptoms may occur: a feeling of dryness in the oropharynx; pain worsening upon swallowing; hoarseness of voice.

Objective symptoms in individuals of both sexes include: hyperemia and edema of the oropharyngeal mucosa and tonsils with a granular surface and membranous patches.

Gonococcal eye infection

Subjective symptoms in individuals of both sexes include: severe pain in the affected eye, lacrimation, eyelid edema, photophobia, and abundant purulent discharge in the corners of the affected eye.

Objective symptoms in individuals of both sexes include: eyelid edema, hyperemia of the skin and mucous membranes of the affected eye, and abundant purulent discharge in the corners of the affected eye.

Gonococcal Infection in Children

Neonatal gonococcal infection typically involves ocular structures. Vulvovaginitis and urethritis may also occur, as well as disseminated infection manifesting as bacteremia, abscesses, arthritis, and meningitis.

Gonococcal infection in postneonatal and prepubertal children (up to 9–12 years of age inclusive) is almost always associated with sexual contact. Vulvovaginitis is the most frequent manifestation in prepubertal girls. Gonococcal urethritis is possible but rare in prepubertal boys. Anorectal and tonsillopharyngeal infections also occur and are frequently asymptomatic.

Gonococcal pelvioperitonitis and other gonococcal infections of the urogenital organs (epididymitis, orchitis, prostatitis, pelvic inflammatory disease in women).

The diseases are typically accompanied by symptoms of general intoxication: fever, general weakness, fatigue, and an elevated erythrocyte sedimentation rate on clinical blood testing.

Subjective symptoms in women include:

> salpingo-oophoritis: cramping lower abdominal pain, mucopurulent vaginal discharge; in chronic cases, subjective manifestations are less pronounced, and menstrual irregularities are noted;

> endometritis: generally dull, aching lower abdominal pain, mucopurulent vaginal discharge; in chronic cases, subjective manifestations are less pronounced, with frequent scanty post- and intermenstrual spotting.

Objective symptoms in women include:

> salpingo-oophoritis: in acute inflammation, enlarged and tender fallopian tubes and ovaries upon palpation, foreshortening of the vaginal fornices, mucopurulent discharge from the cervical canal; in chronic cases, mild tenderness, induration of the fallopian tubes;

> endometritis: in acute inflammation, a tender, enlarged uterus with a soft consistency, mucopurulent discharge from the cervical canal; in chronic cases, firm consistency and limited mobility of the uterus.

Subjective symptoms in men include:

> epididymitis and epididymoorchitis: urethral mucopurulent discharge, dysuria, dyspareunia, tenderness in the epididymis and inguinal region, most often unilateral; perineal pain radiating to the rectum, lower abdomen, and scrotum; pain may spread to the spermatic cord, inguinal canal, lumbar, and sacral regions;

> prostatitis: perineal and lower abdominal pain radiating to the rectum, dysuria.

Objective symptoms in men include:

> epididymitis and epididymoorchitis: urethral mucopurulent discharge, hyperemia and edema of the scrotum in the affected area, with palpation revealing enlarged, firm, and tender testes and epididymides;

> prostatitis: palpation reveals a tender, indurated prostate gland.

In disseminated gonococcal infection, patients of both sexes may develop pelvioperitonitis, endocarditis, pericarditis, meningitis, arthritis, brain abscess, pneumonia, perihepatitis, sepsis, osteomyelitis, synovitis, lacking pathognomonic symptoms.

Subjective and objective symptoms of gonococcal infection in children and adolescents are similar to those in adults. A feature of the clinical course in girls is more pronounced subjective and objective symptomatology and multi-focal involvement.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis is established solely on the basis of laboratory confirmation of the presence of Neisseria gonorrhoeae in the biological sample studied.

2.1 Complaints and Anamnesis

Subjective clinical manifestations of gonococcal infection are described in the "Clinical Presentation" section.

2.2 Physical Examination

An examination of the skin of the external genitalia and anogenital region, visible mucous membranes of the external genitalia and urethra is performed; the presence and nature of spontaneous discharge are assessed; palpation of the urethra and regional lymph nodes is carried out. Examination of the oropharyngeal mucosa is performed according to indications.

In women: inspection of the vaginal mucosa and speculum examination of the cervix (using a Cusco speculum); assessment of discharge in the posterior and posterior-lateral vaginal fornices and from the cervical canal; bimanual pelvic examination.

In men: palpation of the scrotal contents, digital rectal examination (as clinically indicated).

Objective clinical manifestations of gonococcal infection detected during physical examination are described in the "Clinical Presentation" section.

2.3 Laboratory Diagnostics

■ individuals with clinical and/or laboratory signs of an inflammatory process in the urogenital tract and reproductive system;

■ during preconception evaluation of sexual partners;

■ during the evaluation of women during pregnancy;

■ prior to scheduled surgical (invasive) procedures on the genital organs and pelvic organs;

■ individuals with a history of perinatal loss and infertility;

■ survivors of sexual assault [15, 20].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comments: The sensitivity of microscopic examination in evaluating urethral discharge in men with manifest gonococcal infection is 90-100%, and the specificity is 90-100%. To confirm that the detected diplococci belong to the species Neisseria gonorrhoeae, molecular biological and/or culture tests must be performed. Microscopic examination determines the severity of the inflammatory response.

Comments: The sensitivity and specificity of microscopic examination for cervical, pharyngeal, and rectal samples, as well as for asymptomatic infection, is 45-64% [1-4, 10, 37].

Comments: The diagnosis is established based on the results of laboratory tests using molecular biological methods aimed at detecting specific DNA and/or RNA fragments of N. gonorrhoeae, utilizing test systems approved for medical use in the Russian Federation (PCR, NASBA). The sensitivity of these methods is 98-100%, and specificity is 100%. Various inhibitory factors can affect test sensitivity; therefore, strict requirements are imposed on the organization and operational routine of the laboratory to prevent contamination of clinical specimens.

In women, the sensitivity of molecular genetic methods in urine testing is lower than that in testing biological material from the urogenital system; urine testing is not used to diagnose gonococcal infection in women.

Comments: To obtain reliable laboratory test results, a number of requirements must be met, including:

— timing of obtaining clinical material taking into account the use of antibacterial drugs: for the identification of N. gonorrhoeae by microscopy, culture method, and RNA amplification method (NASBA) — no earlier than 14 days after the end of drug intake; based on DNA amplification methods (PCR, real-time PCR) — no earlier than one month after the end of drug intake;

— obtaining clinical material from the urethra no earlier than 3 hours after the last urination; in the presence of abundant urethral discharge — 15–20 minutes after urination;

— obtaining clinical material from the cervical canal and vagina outside of menstruation;

— compliance with the conditions for sample transport to the laboratory.

2.4 Instrumental Diagnostics

Not applicable.

2.5 Other Procedures

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

To achieve N. gonorrhoeae eradication and clinical recovery, gonococcal infection is treated with systemic antibacterial drugs.

3.1 Conservative Treatment

ceftriaxone** [12–15, 19, 44, 45].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comments: According to global data on the increasing antibiotic resistance of N. gonorrhoeae to the drugs used, ceftriaxone** is used at a dosage of 1 g intramuscularly once [12–15, 19, 44, 45].

or

cefixime 400 mg orally once [12–15, 19].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

or

spectinomycin 2.0 g intramuscularly once [12, 19, 20].

GCR CLEL 5Grade of recommendation - C (level of evidence 5)

Comments: According to global data, ceftriaxone** is used at 500 mg intramuscularly once daily for 3 days [12–15, 19, 20, 21].

ceftriaxone** [12–15, 18, 19, 44, 45].

GCR CLEL 5Grade of recommendation - C (level of evidence 5)

Comments: According to global data, ceftriaxone** is used at 1 g intramuscularly once [12–15, 18, 19, 44, 45].

or

cefixime 400 mg orally once [12–15, 18, 19].

GCR CLEL 5Grade of recommendation - C (level of evidence 5)

ceftriaxone** 1.0 g intramuscularly or intravenously every 24 hours for 14 days [12–15, 18, 19, 48].

GCR CLEL 5Grade of recommendation - C (level of evidence 5)

or

cefotaxime** 1.0 g intravenously every 8 hours for 14 days [12–15, 18, 19, 48].

GCR CLEL 5Grade of recommendation - C (level of evidence 5)

Comments: 24–48 hours after the start of parenteral antibacterial therapy, provided that clinical symptoms of the disease have resolved, it is possible to continue therapy with third-generation cephalosporins orally [13–14, 19, 22–25].

ceftriaxone** [20, 26, 27, 42, 43, 44, 45].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: According to global data on the increasing antibiotic resistance of N. gonorrhoeae to the drugs used, ceftriaxone** is used for strict indications at a dosage of 1 g intramuscularly once [20, 26, 27, 42, 43, 44, 45].

or

cefixime 400 mg orally once [26, 27].

GCR ALEL 2Grade of recommendation A (level of evidence 2)

Comments: Pregnant patients with gonococcal infection are treated at any gestational age with antibacterial drugs taking into account their effect on the fetus, with the participation of obstetrician-gynecologists.

ceftriaxone** [13–15, 29, 31–33, 34, 49].

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comments: According to global data, it is used at a dosage of 125 mg intramuscularly once [49].

or

spectinomycin 40 mg per kg of body weight (not exceeding 2.0 g) intramuscularly once [13–15, 29, 31–33, 34].

GCR CLOCE 5Grade of Recommendation C (Level of Evidence 5)

Comments: Spectinomycin is contraindicated in children under 3 years of age. Treatment of gonococcal infection in children weighing more than 45 kg is carried out in accordance with adult dosing regimens. In confirmed gonococcal infection in children, sexual transmission must be ruled out.

ceftriaxone** [29, 30, 31, 45].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comments: Neonates born to mothers with gonococcal infection are managed with the participation of neonatologists. According to international practice, ceftriaxone** is administered at 25–50 mg/kg of body weight (not exceeding 125 mg) intramuscularly or intravenously once daily for 3 days [29, 30, 31, 45].

Erythromycin, 0.5% eye ointment once [27–29, 31, 34].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comments: According to international data, prophylactic treatment is also administered to newborns born to mothers with gonococcal infection, even in the absence of gonococcal infection in the newborn, using ceftriaxone** 25–50 mg/kg of body weight (but not exceeding 125 mg) intramuscularly as a single dose [29–31].

Comments: antibacterial therapy for gonococcal infection should not be supplemented with systemic enzyme therapy, immunomodulating therapy, or treatment with antiseptics and disinfectants [31, 34, 46].

3.2. Surgical treatment

Not applicable.

3.3. Other treatment

Diet therapy is not indicated.

Pain management is not performed.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

Prevention

• avoiding casual sexual contacts;

• using barrier contraception methods;

• examination and treatment of sexual partners [39].

Dispensary monitoring (active follow-up)

— to rule out reinfection;

— to perform tests to determine the susceptibility of N. gonorrhoeae to antibacterial drugs;

— to prescribe antibacterial drugs of other pharmacological groups based on the susceptibility testing results of the isolated strains [34, 39].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

6. Organization of Medical Care

There are no indications for hospitalization in a medical organization.

Medical care is provided as part of primary specialized healthcare by dermatovenereologists in an outpatient setting.

Cure criteria:

— eradication of N. gonorrhoeae is achieved;

— disappearance of clinical symptoms of the disease (clinical cure) is achieved.

When a patient is identified, form No. 089-u/kv "Notification of a patient with a newly diagnosed case of: syphilis, gonococcal infection, chlamydial infections, trichomoniasis, anogenital viral herpes infection, anogenital (venereal) warts, mycosis, scabies" is filled out in the manner established by the letter of the Ministry of Health of the Russian Federation dated March 2, 2015, No. 13-2/25.

7. Additional Information

Patients with a diagnosed gonococcal infection must be screened for other sexually transmitted infections. Determination of hepatitis B virus (Hepatitis B virus) surface antigen (HBsAg) in the blood; determination of classes M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-1 (Human immunodeficiency virus HIV 1) in the blood; determination of classes M and G antibodies (IgM, IgG) to human immunodeficiency virus HIV-2 (Human immunodeficiency virus HIV 2) in the blood; qualitative and semi-quantitative determination of antibodies to Treponema pallidum in non-treponemal tests (RPR, VDRL) in blood serum; determination of Hepatitis C virus antigen in the blood.

If the source of infection is unidentified, repeat serological testing for syphilis is recommended after 3 months, and for HIV, hepatitis B, and C - after 3–6–9 months. If the HIV status is unknown or previously negative at the time of diagnosis and after 6 months, HIV testing is recommended.

Criteria for Evaluating the Quality of Medical Care

*only when examining urethral discharge in men with manifest manifestations of gonococcal infection

References

Appendix A1. Working Group Composition

1. Kubanov Alexey Alekseevich - Academician of the Russian Academy of Sciences, President of the Association of Dermatovenereologists and Cosmetologists (_OOO RODVK_), Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health.

2. Serov Vladimir Nikolaevich - Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, President of the Russian Association of Obstetricians and Gynecologists.

3. Abuduev Nazirbek Karimullaevich - Doctor of Medical Sciences, Senior Researcher at the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

4. Apolikhina Inna Anatolyevna - Doctor of Medical Sciences, Professor, Head of the Department of Aesthetic Gynecology and Rehabilitation at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

5. Bogdanova Elena Vitalievna - Senior Researcher at the Scientific and Organizational Department of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

6. Vasiliev Mikhail Mikhailovich - Doctor of Medical Sciences, Professor, Leading Researcher at the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

7. Gerasimova Natalia Avenirovna - Candidate of Biological Sciences, Senior Researcher at the Scientific Experimental Laboratory Department of the Ural Research Institute of Dermatovenereology and Immunopathology, Yekaterinburg, member of the Russian Society of Dermatovenereologists and Cosmetologists.

8. Gomberg Mikhail Alexandrovich - Doctor of Medical Sciences, Professor, Chief Researcher at the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology of the Moscow Healthcare Department, member of the Union "National Alliance of Dermatovenereologists and Cosmetologists", Member of the Royal College of Physicians (RCP), Member of the American Academy of Dermatology (AAD), member of the European Academy of Dermatology and Venereology (EADV), Senior Advisor to the International Union against Sexually Transmitted Infections (IUSTI).

9. Dolgushina Natalia Vitalievna - Doctor of Medical Sciences, Professor, Deputy Director - Head of the Department for Organization of Scientific Activity at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

10. Zemtsov Mikhail Alekseevich - Candidate of Medical Sciences, Honored Doctor of the Russian Federation, Chief Physician of the Stavropol Krai Clinical Dermatovenereology Dispensary, Chief Freelance Dermatovenereologist and Cosmetologist of the Ministry of Health of Stavropol Krai, member of the Russian Society of Dermatovenereologists and Cosmetologists.

11. Ziganshin Oleg Raisovich - Doctor of Medical Sciences, Professor, Chief Physician of the Chelyabinsk Regional Clinical Dermatovenereology Dispensary, Head of the Department at the South Ural State Medical University of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

12. Georgy Leonidovich Katunin - Candidate of Medical Sciences, Dermatovenereologist at the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, Member of the Russian Society of Dermatovenereologists and Cosmetologists.

13. Roman S. Kozlov - Corresponding Member of the RAS, Doctor of Medical Sciences, Professor at the Research Institute of Antimicrobial Chemotherapy, Smolensk State Medical Academy.

14. Lyudmila A. Lyubasovskaya - Candidate of Medical Sciences, Head of the Department of Clinical Pharmacology of Antimicrobial and Immunobiological Drugs at the Institute of Microbiology, Antimicrobial Therapy and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

15. Elena A. Mezhevitinova - Doctor of Medical Sciences, Leading Researcher at the Scientific-Polyclinical Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

16. Iskander K. Minullin - Chief Physician of the Republican Clinical Skin and Venereological Dispensary, member of the Russian Society of Dermatovenereologists and Cosmetologists.

17. Irina A. Nechaeva - Candidate of Medical Sciences, Dermatovenereologist at the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

18. Viktoriya V. Onipchenko - Chief Physician of the Novosibirsk Regional Clinical Skin and Venereological Dispensary, Chief Specialist in Dermatovenereology and Cosmetology of the Novosibirsk Oblast, member of the Russian Society of Dermatovenereologists and Cosmetologists.

19. Yury N. Perlamutrov - Doctor of Medical Sciences, Professor at the A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

20. Plakhova Ksenia Ilyinichna - Doctor of Medical Sciences, Scientific Secretary, Acting Head of the STI Department, State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenerologists and Cosmetologists.

21. Nikolay N. Potekaev - Doctor of Medical Sciences, Professor, Director of the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology of the Moscow City Health Department, Chief Freelance Specialist in Dermatovenereology and Cosmetology of the Russian Ministry of Health, Head of the Department of Skin Diseases and Cosmetology at the Faculty of Postgraduate Medical Education of the N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health, President of the National Alliance of Dermatologists and Cosmetologists of Russia.

22. Tatyana V. Priputnevich - Doctor of Medical Sciences, Head of the Department of Microbiology, Clinical Pharmacology and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.

23. Sergey V. Prozherin - Dermatovenereologist at the Sverdlovsk Regional Center for Prevention and Control of AIDS, member of the Russian Society of Dermatovenereologists and Cosmetologists.

24. Margarita R. Rakhmatulina - Doctor of Medical Sciences, Professor at the Department of Dermatovenereology and Cosmetology with a Course of Clinical Laboratory Diagnostics, A.I. Burnazyan Federal Medical Biophysical Center of the Federal Medical-Biological Agency of Russia, member of the Russian Society of Dermatovenereologists and Cosmetologists.

25. Evgeny V. Sokolovsky - Doctor of Medical Sciences, Professor, Head of the Department of Dermatovenereology with a Clinic, Academician I.P. Pavlov First Saint Petersburg State Medical University, member of the Russian Society of Dermatovenereologists and Cosmetologists.

26. Viktoriya S. Solomka - Doctor of Biological Sciences, Deputy Director for Scientific Work at the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

27. Tatyana A. Sysoeva - Candidate of Medical Sciences, Associate Professor at the Department of Dermatovenereology and Cosmetology, Russian Medical Academy of Continuing Professional Education, member of the Russian Society of Dermatovenereologists and Cosmetologists.

28. Igor S. Tartakovsky - Doctor of Medical Sciences, Professor, Chairman of the Microbiology Committee of the Federation of Laboratory Medicine.

29. Natalya V. Frigo - Doctor of Medical Sciences, Deputy Director for Science at the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology of the Moscow City Health Department, member of the National Alliance of Dermatovenereologists and Cosmetologists Union.

30. Aleksey A. Khryanin - Doctor of Medical Sciences, Professor at the Department of Dermatovenereology and Cosmetology, Novosibirsk State Medical University of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

31. Vadim V. Chikin - Senior Researcher at the Department of Dermatology, State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Medical specialists: dermatovenereologists, obstetricians-gynecologists, urologists, pediatricians;

2. Residents and trainees of continuing professional education courses in the specified specialties.

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for their systematic review at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to the previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile of 'Dermatovenereology'"

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1. To prevent reinfection with the causative agent of gonococcal infection, examination and treatment of sexual partners are required.

2. During the period of treatment and dispensary follow-up, it is necessary to abstain from sexual contact or use barrier methods of contraception until cure is established.

3. To establish cure, a repeat visit to the physician for examination is required (using microscopic, microbiological methods, NASBA 14 days after the end of treatment, PCR or real-time PCR methods - no earlier than one month after the end of treatment).

4. Examination for other sexually transmitted infections is recommended.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

There is no universally accepted rating scale.