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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

Gonorrhea

California STD/HIV Prevention Training CenterSTD Clinical Series

neisseria gonorrhoeae
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
history of gc
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”
risk factors for gc infection
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
gc sexual transmission
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
gc microbiology
GC Microbiology
  • Gram-negative diploccocus
  • Infects non-cornified epithelium
    • Cervix
    • Urethra
    • Rectum
    • Pharynx
    • Conjunctiva
  • Observed intracellularly in PMNs on Gram stain
gc pathogenesis
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
gonococcal infections in women
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
slide9
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

gonococcal cervicitis
Gonococcal Cervicitis
  • Incubation 3-10 days
  • Symptoms:
    • Vaginal discharge
    • Dysuria
    • Vaginal bleeding
  • Cervical signs :
    • Erythema
    • Friability
    • Purulent exudate

STD Atlas, 1997

pelvic inflammatory disease
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

gonococcal bartholinitis
Gonococcal Bartholinitis
  • Tender swollen Bartholin’s gland with purulent discharge
  • Infection at other sites common

STD Atlas, 1997

bartholin s abscess
Bartholin’s Abscess
  • Painful swollen Bartholin’s glands
  • Fluctuant, tender
  • May have expressible purulent discharge
gonococcal infections in men
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

gonococcal urethritis
Gonococcal Urethritis
  • Incubation 2-7 days
  • Abrupt onset of severe dysuria
  • Purulent urethral discharge
  • Most urethral infections symptomatic

STD Atlas, 1997

epididymitis
STD Atlas, 1997Epididymitis

Epididymitis

  • Swollen painful epididymis
  • Urethritis
  • Epididymal tenderness or mass on exam
gonococcal infections in women men
Gonococcal Infections in Women & Men
  • Urethritis
  • Proctitis
  • Pharyngeal infections
  • Conjunctivitis
  • Disseminated Gonococcal Infection
gonococcal ophthalmia in the adult
Gonococcal Ophthalmiain the Adult
  • Marked chemosis and tearing
  • Typically purulent discharge, erythema

STD Atlas, 1997

gonococcal ophthalmia in the adult19
Gonococcal Ophthalmia in the Adult
  • Conjunctival erythema and discharge
disseminated gonococcal infection
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
dgi clinical manifestations
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
dgi skin lesion
DGI Skin Lesion
  • Necrotic, grayish central lesion on erythematous base

STD Atlas, 1997

dgi skin lesion23
DGI Skin Lesion
  • Papular and pustular lesions on the foot

STD Atlas, 1997

dgi skin lesion24
DGI Skin Lesion
  • Small painful midpalmar lesion on an erythematous base

STD Atlas, 1997

dgi skin lesion25
DGI Skin Lesion
  • Pustular erythematous lesions
dgi skin lesion26
DGI Skin Lesion
  • Papular erythematous skin lesion
dgi differential diagnosis
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
gonococcal complications in pregnancy
Gonococcal Complications in Pregnancy
  • Postpartum endometritis
  • Septic abortions
  • Post-abortal PID

Possible role in:

    • Gestational bleeding
    • Preterm labor and delivery
    • Premature rupture of membranes
vertical transmission and neonatal complications on gonorrhea
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
gonococcal ophthalmia neonatorum
Gonococcal Ophthalmia Neonatorum
  • Lid edema, erythema and marked purulent discharge
  • Preventable with ophthalmic ointment

STD Atlas, 1997

gc infections in children
GC Infections in Children
  • Vulvovaginits
  • Urethritis
  • Proctitis
  • All cases should be considered possible evidence of sexual abuse
  • Culture should be obtained
gc diagnostic methods
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
gonorrhea diagnostic tests
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

gc gram stain
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
gram stain for gc urethral smear
Gram Stain for GC: Urethral Smear
  • Numerous PMNs
  • Gram negative intracellular diplococci

STD Atlas, 1997

gram stain for gc cervical smear
Gram Stain for GC: Cervical Smear
  • PMN with Gram negative intracellular diplococci

STD Atlas, 1997

gc culture
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
gc culture candle jar
GC Culture Candle Jar

STD Atlas, 1997

gonorrhea treatment genital rectal infections in adults
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

gonorrhea treatment genital rectal infections in adults42
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

empiric co treatment of ct infections
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
gonorrhea treatment extra genital sites in adults
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

gonorrhea treatment pregnancy
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

gonorrhea treatment neonates
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

gonorrhea treatment neonates47
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

gonorrhea treatment children
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

dgi treatment initial iv therapy
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

dgi treatment subsequent oral therapy
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

gc antimicrobial resistance
GC Antimicrobial Resistance
  • Resistance in 20%-30% of gonococcal isolates tested in U.S.
  • Plasmid mediated
    • B - Lactamase production
    • High-level tetracycline resistance
  • Chromosomal mediated
    • Confers resistance to PCN, tetracycline, spectinomycin, erythromycin, fluoroquinolones, and/or cephalosphorins
use of fluoroquinolones to treat gc infection
Use of Fluoroquinolones to Treat GC Infection
  • CipR GC up to 40% in Japan, Philippines, parts of SE Asia and the Pacific Islands
  • CipR in Hawaii over 10%
  • Antimicrobial resistance to fluoroquinolones increasing in the continental U.S., but still < 1%
  • Providers should get a travel history and if infection may have been acquired in Hawaii, Asia or the Pacific Islands, patient should be treated with a cephalosporin
  • Treatment failures should be cultured and tested for resistance (and re-treated)
cipr gc in california
CipR GC in California
  • Prevalence of CipR GC in CA >10% in 2002
  • CA GC Tx Recommendations:
    • Avoid the use of fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin) to treat GC in California.
    • Use ceftriaxone 125mg IM x 1 to treat uncomplicated gonococcal infections of the cervix, urethra, and rectum
    • Note: cefixime is no longer being manufactured.
gc patient counseling
GC Patient Counseling
  • Nature of transmission
  • Potential long term and neonatal complications
  • Abstain from sex for at least 3-4 days during treatment (7 days if co-treated for CT)
  • Warning signs and need for follow up
  • Notification and need for treatment of partners
gc partner management
GC Partner Management
  • All sex partners with contact during 60 days preceding the onset of symptoms or test date should be evaluated, tested & treated
  • If no sex partners in previous 60 days, treat the most recent partner
gc prevention strategies
GC Prevention Strategies
  • Health promotion, education & counseling
  • Increased access to condoms
  • Early detection through screening in selected high risk populations
  • Effective diagnosis & treatment
  • Partner management
  • Risk reduction counseling
gonorrhea screening california provisional guidelines
Gonorrhea ScreeningCalifornia Provisional Guidelines
  • Adolescent females from high prevalence areas
  • All patients with other STDs
  • MSMs with high risk behaviors
  • Pregnant women < 25 years old
  • Adolescents in juvenile halls
gonorrhea screening in pregnancy
Gonorrhea Screening in Pregnancy
  • Screen in 1st trimester and again in 3rd trimester (~32 weeks) for high-risk or high prevalence patients
  • High risk includes new partners, multiple partners, non-mutually monogamous relationship, concurrent STDs
  • Higher prevalence among adolescents, urban, low SES, certain geographic areas
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