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gonorrhea

Etiology: - venereal disease resulting from infection with Neisseria gonorrhoeae - susceptibility increased with complement deficiency (C5,C6,C7,C8 deficiency) [3] - deep kissing alone in men who have sex with men [34] Epidemiology: 1) sexually active individuals 2) more common in females 3) complement deficiency predisposes 4) prevalence 0.1% white; 0.2% latinos, 2.1% blacks [10] in adolescents grades 7-12 - may occur concurrently with Chlamydia) [5] 5) antibiotic resistant gonorrhea increasing [28] - 1st known case of ceftriaxone-resistant gonorrhea identified from a woman in Canada [30] Clinical manifestations: 1) dysuria, urinary frequency 2) males a) green, yellow or sanguineous urethral discharge - purulent or mucopurulent urethral discharge [3] b) meatus swollen & red c) urethritis, urethral pain, epididymitis d) proctitis (homosexual men) 3) females a) purulent urethral discharge - mucopurulent cervicitis [3] b) urethral inflammation, urethritis & cervicitis c) swelling or tenderness in Skene or Bartholin gland d) pelvic inflammatory disease 4) pharyngitis after oral sex 5) infection may be asymptomatic 6) disseminated gonococcemina is characterized by a) tenosynovitis - Finkelstein's sign may be positive - tendon sheath inflammation b) monoarthritis or oligoarthritis (knees, hips, wrists) c) polyarthragia, migratory arthritis d) purulent conjunctivitis may be present e) symptoms of fever, chills & malaise may precede migratory arthritis & rash by a week or two f) skin lesions 1] papules (1-5 mm) evolving in 1-2 days into hemorrhagic pustules with gray necrotic centers 2] hemorrhagic bullae occur rarely 3] generally multiple lesions, but < 40 4] lesions distributed peripherally near joints 5] lesions more common on upper extremities 6] lesions may be on trunk 7] vesiculopustular palmar rash g) purulent monoarthritis or oligoarthritis may occur without dermatitis or fever [3] h) no flu-like symptoms preceding rash or arthritis (see parvovirus B19) * image [37] Laboratory: 1) gram stain: a) intracellular Gm- diplococci b) useful in men, less so in women (not useful for cervicitis) 2) culture on selective media a) Thayer-Martin, Martin-Lewis, NYC b) best test for proctitis, pharyngitis 3) molecular diagnostic testing - Neisseria gonorrhoeae DNA &/or Neisseria gonorrhoeae rRNA - Chlamydia trachomatis+Neisseria gonorrhoeae DNA - Chlamydia trachomatis/Neisseria gonorrhoeae rRNA - best test for cervicitis [20] - endocervical swab (women) or urethral swab (men) [19] - rectal swab or oropharyngeal swab as indicated - urine may be acceptable 4) Chlamydia+gonorrhea point of care test [35] - results available in 30 minutes - allows one visit diagnoisis & treatment 5) joint fluid culture for monoarticular arthritis 6) blood culture for disseminated infection - in disseminated gonococcal infection, obtain specimens from cervix, urethra, oropharynx & rectum & test for N gonorrhoeae per above [3] 7) if N gonorrhoeae confirmed, test for Chlamydia, syphilis, & HIV [3] 8) CH50 assay screen for complement deficiency: - all patients with recurrent disseminated gonorrhea - family history of disseminated Neisseria infection [3] 9) test of cure only when pharyngeal gonorrhea is treated with alternative antibiotic regimen [3] Complications: 1) endocarditis 2) meningitis 3) antibiotic resistance more common isolates from men who have sex with men, than men who have sex with women (exclusively) [18] Differential diagnosis: - parvovirus B19 infection - a flu-like syndrome of headache, fever, myalgia may precede rash - facial 'slapped cheek' rash in children - symmetric polyarticular arthritis - a negative history of sexual activity increases likelihood of parvovirus B19 - purulent conjunctivitis not a feature of parvovirus B19 - migratory arthritis not a feature of parvovirus B19 Management: 1) uncomplicated mucosal infection (cervicitis, urethritis, proctitis) a) ceftriaxone 500 mg IM single dose for uncomplicated gonorrhea - if > 150 kg, q single 1 g IM dose of ceftriaxone [36] - ceftriaxone 250 mg IV/IM plus doxycycline 100 mg PO BID x 7 days or oral azithromycin 1 g (once if pregnant) [13,16,32] - single case of ceftriaxone-resistant gonorrhea (2017) [30] - increased efficacy of ceftriaxone-azithromycin combination for N gonorrhoeae [3] b) include doxycycline 100 mg PO BID x 7 days for treatment of epididymitis in sexually active men < 35 years or if chlamydia has not been ruled out [36] c) cefixime (800 mg single oral dose) [36] plus azithromycin or doxycycline if ceftriaxone is not available - recommend test-of-cure at 1 week [16] d) cefixime treatment failures should receive ceftriaxone 250 mg IV/IM plus 2 g of azithromycin e) ceftriaxone treatment failures should prompt consultation with an infectious disease specialist & the CDC [13] f) wide fluctuations in susceptibility of N gonorrhoeae to cephalosporins, especially, cefixime [22] g) dual therapy recommended over single therapy [26,27] h) no reliable alternatives to ceftriaxone for pharyngeal gonorrhea [3] i) test-of-cure at 1 week for pharyngeal gonococcus [36] 2) if pregnant: a) 3rd generation cephalosporin IV/IM once (ceftriaxone 250 mg IV/IM), plus b) erythromycin 500 mg PO QID for 7 days or azithromycin 1 g PO (once) 3) if allergic to cephalosporins: a) spectinomycin 2 g IM once [3] b) azithromycin 2 g PO plus gentamicin 240 mg IM or gemifloxacin 320 mg PO once [21] - adverse effects of high-dose azithromycin common - exposure to azithromycin <= 30 days prior to diagnosis of gonorrhea results in higher MICs, but still below the defined resistance of >= 1.0 mg/L [29] c) CDC recommends NOT using quinolones for treatment of gonorrhea [9,11] 4) avoid fluoroquinolones, resistance is common 5) sexual partners should be offered evaluation & treatment 6) disseminated gonorrhea a) ceftriaxone 1 g IV QD for 10-14 days [3] b) ceftriaxone 1 g IV for 3-4 days or until clinical improvement, followed by cefixime or ciprofloxacin to complete a course of 7-10 days c) if allergic to cephalosporins, spectinomycin 2 g IM BID for 3 days 7) chlamydial infections may co-exist with gonorrhea & should be treated a) doxycycline 100 mg PO BID x 7 days unless pregnant b) single dose of azithromycin if pregnant 8) cefixime 400 mg & azithromycin 1 g (single oral dose) can be used to treat both chlamydia & primary gonorrhea - Suprax discontinued 2003; back on the market in summer 2004 [7,8] 9) single dose of 2 grams of azithromycin a) will erradicate both gonorrhea & chlamydia, b) associated with significant GI side effects c) concern for Neisseria gonorrhoeae resistance 10) emergence of cephalosporin-resistant gonorrhea [15,17] - increaseing resistance to ceftriaxone + azithromycin [25] 11) Listerine antiseptic mouthwash (1 minute) effective for oropharyngeal gonorrhea [27] 12) screening a) screen sexually-active women < 25 year of age for Chlamydia trachomatis & Neisseria gonorrhoeae [20] b) screen women > 25 year of age with risk factors for Chlamydia trachomatis & Neisseria gonorrhoeae [20] 13) behavioral counseling for sexually-active women < 25 years of age & older women at risk [20]

Related

Neisseria gonorrhoeae (gonococcus, GC) Neisseria gonorrhoeae DNA

General

bacterial infection sexually-transmitted disease; sexually-transmitted infection; venereal disease (STD, STI)

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 873
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 529, 531
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  4. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 95
  5. Journal Watch 22(1):3, 2002 Best D et al Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection in pediatric private practice. Pediatrics 108:e103, 2001 PMID: 11731630
  6. Prescriber's Letter 9(6):31 2002
  7. Prescriber's Letter 10(1):3 2003
  8. Cefixime (Suprax) Returns to the Market in the United States Prescriber's Letter 11(4):21 2004 Detail-Document#: 200409 (subscription needed) http://www.prescribersletter.com
  9. Prescriber's Letter 11(6):33 2004 Detail-Document#: 200607 (subscription needed) http://www.prescribersletter.com - Journal Watch 24(11):90, 2004 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5316a1.htm
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  11. Prescriber's Letter 14(5): 2007 Updated summary of CDC STD guidelines Summary of 2006 Canadian STI Guidelines CDC recommendations for gonorrhea treatment Detail-Document#: 230502 (subscription needed) http://www.prescribersletter.com
  12. Prescriber's Letter 15(6): 2008 Expedited Partner Therapy (EPT) for Chlamydia and Gonorrhea Detail-Document#: 240601 (subscription needed) http://www.prescribersletter.com
  13. Centers for Disease Control and Prevention Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000--2010 MMWR. July 8, 2011 / 60(26);873-877 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a2.htm
  14. Prescriber's Letter 18(9): 2011 COMMENTARY: Antibiotic-resistant Gonorrhea: A Growing Public Health Concern CHART: Sexually Transmitted Diseases Treatment Guidelines Detail-Document#: 270907 (subscription needed) http://www.prescribersletter.com
  15. WHO: Urgent action needed to prevent the spread of untreatable gonorrhoea http://www.who.int/mediacentre/news/notes/2012/gonorrhoea_20120606/en/index.html - Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae http://whqlibdoc.who.int/publications/2012/9789241503501_eng.pdf
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  21. Kirkcaldy RD et al. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Clin Infect Dis 2014 Oct 15; 59:1083. PMID: 25031289 http://cid.oxfordjournals.org/content/59/8/1083
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