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Gonorrhea

Gonorrhea. California STD/HIV Prevention Training Center STD Clinical Series. Neisseria gonorrhoeae. Gram-negative diplococcus Infects non-cornified epithelium. Second m ost common bacterial STD Estimated >1 million US cases per year Incidence highest among adolescents and young adults

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Gonorrhea

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  1. Gonorrhea California STD/HIV Prevention Training CenterSTD Clinical Series

  2. Neisseria gonorrhoeae • Gram-negative diplococcus • Infects non-cornified epithelium • Second most common bacterial STD • Estimated >1 million US cases per year • Incidence highest among adolescents and young adults • Causes a range of clinical syndromes • Many infections are asymptomatic

  3. History of GC • Neisseria gonorrhoeae described by Albert Neisser in 1879 • Observed in smears of purulent exudates of urethritis, cervicitis, opthalmia neonatorum • Thayer Martin medium enhanced isolation of gonococcus in 1960 • AKA “The Clap”

  4. Risk Factors for GC Infection • Urban and low SES populations • Adolescents > age 20-25 years > older • Black/Hispanic > White/API • Multiple sex partners • Inconsistent use of barrier methods • High prevalence in sexual network

  5. GC Sexual Transmission • Efficiently transmitted by sexual contact • Greater efficiency of transmission from male to female • Male to female: 50 - 90% • Female to male: 20 - 80% • Vaginal & anal intercourse more efficient than oral • Can be acquired from asymptomatic partner • Increases transmission and susceptibility to HIV 2-5 fold

  6. GC Microbiology • Gram-negative diploccocus • Infects non-cornified epithelium • Cervix • Urethra • Rectum • Pharynx • Conjunctiva • Observed intracellularly in PMNs on Gram stain

  7. GC Pathogenesis • GC are ingested, evade host defenses, and spread through subepithelial tissues • Attachment mediated by pili • Divides every 20-30 minutes • Leads to formation of submucosal abscesses and accumulation of exudate in lumen • GC toxins damage cells

  8. Gonococcal Infections in Women • Cervicitis • Urethritis • Proctitis • Accessory gland infection (Skene, Bartholin) • Pelvic inflammatory disease (PID) • Peri-hepatitis (Fitz-Hugh-Curtis) • Pregnancy morbidity • Conjunctivitis Many infections asymptomatic • Pharyngitis • DGI

  9. Complications of GC Infections in Women • Infertility • Ectopic Pregnancy • Chronic Pelvic Pain • Psychosocial Upper Tract Infection Local Invasion Systemic Infection Genital Infection Congenital Infection HIV Infection

  10. Gonococcal Cervicitis • Incubation 3-10 days • Symptoms: • Vaginal discharge • Dysuria • Vaginal bleeding • Cervical signs : • Erythema • Friability • Purulent exudate STD Atlas, 1997

  11. Pelvic Inflammatory Disease • Sx: lower abdominal pain • Signs: CMT, uterine/ adnexal tenderness, +/- fever • Laparoscopy may show hydrosalpinx, inflammation, abscess, adhesions Adhesions Tube PID often silent STD Atlas, 1997

  12. Gonococcal Bartholinitis • Tender swollen Bartholin’s gland with purulent discharge • Infection at other sites common STD Atlas, 1997

  13. Bartholin’s Abscess • Painful swollen Bartholin’s glands • Fluctuant, tender • May have expressible purulent discharge

  14. Gonococcal Infections in Men • Pharyngitis • DGI • Urethral stricture • Penile edema • Urethritis • Epididymitis • Proctitis • Conjunctivitis • Abscess of Cowper’s/Tyson’s glands • Seminal vesiculitis • Prostatitis Many infections asymptomatic

  15. Gonococcal Urethritis • Incubation 2-7 days • Abrupt onset of severe dysuria • Purulent urethral discharge • Most urethral infections symptomatic STD Atlas, 1997

  16. STD Atlas, 1997 Epididymitis Epididymitis • Swollen painful epididymis • Urethritis • Epididymal tenderness or mass on exam

  17. Gonococcal Infections in Women & Men • Urethritis • Proctitis • Pharyngeal infections • Conjunctivitis • Disseminated Gonococcal Infection

  18. Gonococcal Ophthalmiain the Adult • Marked chemosis and tearing • Typically purulent discharge, erythema STD Atlas, 1997

  19. Gonococcal Ophthalmia in the Adult • Conjunctival erythema and discharge

  20. Disseminated Gonococcal Infection • Gonococcal bacteremia • Sources of infection include symptomatic and asymptomatic infections of pharynx, urethra, cervix • Occurs in < 5% of GC-infected patients • More common in females • Patients with congenital deficiency of C7, C8, C9 are at high risk

  21. DGI Clinical Manifestations • “Dermatitis-arthritis syndrome” • Arthritis: 90% • Characterized by fever, chills, skin lesions, arthralgias, tenosynovitis • Less commonly, hepatitis, myocarditis, endocarditis, meningitis • Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities

  22. DGI Skin Lesion • Necrotic, grayish central lesion on erythematous base STD Atlas, 1997

  23. DGI Skin Lesion • Papular and pustular lesions on the foot STD Atlas, 1997

  24. DGI Skin Lesion • Small painful midpalmar lesion on an erythematous base STD Atlas, 1997

  25. DGI Skin Lesion • Pustular erythematous lesions

  26. DGI Skin Lesion • Papular erythematous skin lesion

  27. DGI Differential Diagnosis • Meningococcemia • Staphylococcal sepsis or endocarditis • Other bacterial septicemias • Acute HIV infection • Thrombocytopenia & arthritis • Hepatitis B prodrome • Reiter’s Syndrome • Juvenile Rheumatoid Arthritis • Lyme disease

  28. Gonococcal Complications in Pregnancy • Postpartum endometritis • Septic abortions • Post-abortal PID Possible role in: • Gestational bleeding • Preterm labor and delivery • Premature rupture of membranes

  29. Vertical Transmission and Neonatal Complications on Gonorrhea Overall vertical transmission rate ~30% Neonatal complications include: • Ophthalmia neonatorum • Disseminated gonococcal infection (sepsis, arthritis, meningitis) • Scalp abscess (if fetal scalp monitor used) • Vaginal and rectal infections • Pharyngeal infections

  30. Gonococcal Ophthalmia Neonatorum • Lid edema, erythema and marked purulent discharge • Preventable with ophthalmic ointment STD Atlas, 1997

  31. GC Infections in Children • Vulvovaginits • Urethritis • Proctitis • All cases should be considered possible evidence of sexual abuse • Culture should be obtained

  32. GC Diagnostic Methods • Gram stain smear • Culture • Antigen Detection Tests: EIA & DFA • Nucleic Acid Detection Tests • Probe Hybridization • Nucleic Acid Amplification Tests (NAATs) • Hybrid Capture

  33. Gram stain (male urethra exudate) DNA probe Culture NAATs * Sensitivity 90-95% 85-90% 80-95% 90-95% Gonorrhea Diagnostic Tests Specificity  95%  95%  99%  98% * Able to use URINE specimens

  34. GC Gram Stain • In symptomatic male urethritis: • >95% sensitivity and specificity: reliable to diagnose and exclude GC • In cervicitis: • 50-70%sensitivity, 95% specificity • Not useful in pharyngeal infections • Accessory gland infection: similar to male urethritis • Proctitis: similar to cervicitis

  35. Gram Stain for GC: Urethral Smear • Numerous PMNs • Gram negative intracellular diplococci STD Atlas, 1997

  36. Gram Stain for GC: Cervical Smear • PMN with Gram negative intracellular diplococci STD Atlas, 1997

  37. GC Culture • Requires selective media with antibiotics to inhibit competing bacteria (Modified Thayer Martin Media, NYC Medium) • Sensitive to oxygen and cold temperature • Requires prompt placement in high-CO2 environment (candle jar, bag and pill, CO2 incubator) • In cases of suspected sexual abuse, culture is the only test accepted for legal purposes

  38. GC Culture Candle Jar STD Atlas, 1997

  39. GC Culture Specimen Streaking Cervical and Urethral STD Atlas, 1997

  40. GC Culture After 24 Hours STD Atlas, 1997

  41. Gonorrhea TreatmentGenital & Rectal Infections in Adults Recommended regimens: • Cefixime 400 mg PO x 1 or • Ceftriaxone 125 mg IM x 1 or • Ciprofloxicin 500 mg PO x 1 or • Ofloxacin 400 mg PO x 1 or • Levofloxacin 500 mg PO x 1 PLUS if chlamydia is not ruled out: • Azithromycin 1 g PO x 1 or • Doxycycline 100 mg PO BID x 7 d All sex partners within past 60 days need evaluation and treatment CDC 2002 Guidelines

  42. Gonorrhea TreatmentGenital & Rectal Infections in Adults Alternative regimens: • Ceftizoxime 500 mg IM x 1 • Cefotaxime 500 mg IM x 1 • Cefoxitin 2 g IM x 1 plus probenecid 1 g PO x 1 • Gatifloxacin 400 mg PO x 1 • Lomefloxacin 400 mg PO x 1 • Norfloxacin 800 mg PO x 1 • Spectinomycin 2 g IM x 1 CDC 2002 Guidelines

  43. Empiric Co-Treatment of CT Infections • Empiric co-treatment for chlamydia is cost effective if co-infection rate 20-40% and doxycycline used • Prevalence monitoring in California demonstrates that ~50% of GC cases are co-infected with CT • Consider testing rather than treating if local co-infection is low

  44. Gonorrhea TreatmentExtra-Genital Sites in Adults Pharyngeal infection: • Ceftriaxone 125 mg IM x 1 or • Ciprofloxicin 500 mg PO x 1 or PLUS if chlamydia is not ruled out: • Azithromycin 1 g PO x 1 or • Doxycycline 100 mg PO BID x 7 d Conjunctivitis: • Ceftriaxone 1 g IM x 1 dose CDC 2002 Guidelines

  45. Gonorrhea TreatmentPregnancy Must avoid quinolones & tetracycline Recommended regimens: • Cefixime 400 mg PO x 1 • Ceftriaxone 125 mg IM x 1 PLUSif chlamydia is not ruled out: • Azithromycin 1 g PO x 1  • Other appropriate chlamydial regimen Test of cure in 3-4 weeks CDC 2002 Guidelines CalSTDCB 2001

  46. Gonorrhea TreatmentNeonates Ophthalmia neonatorum prophylaxis: • Silver nitrate 1% aqueous solution topical x 1 • Erythromycin 0.5% ointment topical x 1 • Tetracycline 1% ointment topical x 1 Ophthalmia neonatorum treatment: • Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125 mg NTE = not to exceed CDC 2002 Guidelines

  47. Gonorrhea TreatmentNeonates Prophylaxis for maternal GC infection: • Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125 mg Disseminated Gonococcal Infection: • Ceftriaxone 25-50 mg/kg/d IV or IM QD x 7 d (use 50 mg/kg/d for older children, treat for 10-14 d if child weighs  45 kg) • Cefotaxime 25 mg/kg IV or IM q12h x 7 d NTE = not to exceed CDC 2002 Guidelines

  48. Gonorrhea TreatmentChildren Uncomplicated genital infection: •  45 kg: same as adults •  45 kg: ceftriaxone 125 mg IM x 1 (alternative spectinomycin 40 mg/kg IM x 1) Disseminated Gonococcal Infection: • Ceftriaxone 25-50 mg/kg/d x 7 d • Use 50 mg/kg/d for older children • Treat for 10-14d if child weighs  45 kg CDC 2002 Guidelines

  49. DGI TreatmentInitial IV Therapy Begin IV therapy for 24-48 hrs, switch to oral therapy for a total of 1 week Recommended regimen: • Ceftriaxone 1g IV or IM q 24 h Alternative Regimens: • Cefotaxime 1 g IV q 8 h • Ceftizoxime 1 g IV q 8 h • Ciprofloxacin 400 mg IV q 12 h • Ofloxacin 400 mg IV q 12 h • Levofloxacin 250 mg IV q 24 h • Spectinomycin 2 g IM q 12 h CDC 2002 Guidelines

  50. DGI TreatmentSubsequent Oral Therapy Oral therapy for total treatment of 1 week: Recommended Regimes: • Cefixime 400 mg PO BID • Ciprofloxacin 500 mg PO BID • Ofloxacin 400 mg PO BID • Levofloxacin 500 mg PO QD CDC 2002 Guidelines

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