//fpnotebook.com/
Neisseria gonorrhoeae
Aka: Neisseria gonorrhoeae, Gonococcal Infection, Gonorrhea, Gonococcus, Gonococci, Gonococcemia, Disseminated Gonococcus, Multi-Resistant Neisseria Gonorrhea, Gonococcal Urethritis, Gonococcal Cervicitis, Gonococcal Proctitis
- See Also
- Sexually Transmitted Disease
- Pelvic Inflammatory Disease
- Urethritis
- Urethritis in Women
- Acute Cervicitis
- Proctitis
- Epidemiology
- Much less common than Chlamydia
- Incidence: 500-700,000 cases per year
- Decreasing except in inner city, Drug Abuse (crack)
- Second most common reportable Sexually Transmitted Disease
- Highly contagious: 50% transmission
- Chlamydia coexists in 45-50% of patients with Gonorrhea
- Most common in young women
- Ages 15 to 19 years old
- Incarcerated women under age 35 years
- Risk Factors
- Adults
- See Sexually Transmitted Disease
- Age <25 years old
- Black race
- Prior Sexually Transmitted Disease
- Drug Abuse
- Prostitutes
- Men who have Sex with Men
- Inconsistent Condom use
- Multiple sex partners
- Children
- Mothers with prior Sexually Transmitted Disease
- Mothers with Substance Abuse
- Mothers without Prenatal Care
- Sexual abuse
- No ophthalmic chemoprophylaxis at delivery (Ocular Gonorrhea)
- References
- (2005) Ann Fam Med 3(3): 263-7 [PubMed]
- Pathophysiology
- Caused by Neisseria gonorrhoeae
- Incubation: 2-7 days
- Findings: Symptoms and Signs - General
- Urinary Symptoms
- Urinary Frequency
- Urinary urgency
- Dysuria
- Copious Urethral discharge
- Green, yellow, or sanguinous discharge
- Meatus and anterior Urethra inflammation
- Conjunctivitis
- Direct inoculation
- Copious exudate
- Beefy Conjunctiva
- Serious complications
- Corneal Ulceration or opacification
- Visual loss
- Globe Perforation
- Pharyngitis
- Rarely the only site of infection
- Accompanies Cervicitis in 10-20% of cases
- Usually asymptomatic or only mild in up to 90% of cases
- Associated with anterior cervical adenopathy
- More common in Men who have Sex with Men, HIV Infection or other STD
- Proctitis
- Receptive anal intercourse (especially in Men who have Sex with Men)
- Mild anal irritation or itching to Rectal Pain
- Mucopurulent discharge
- Painful Defecation or tenesmus
- May cause Acute Diarrhea
- Findings: Symptoms and Signs - Women (asymptomatic in 95% of cases)
- Delayed diagnosis is common with risk of Pelvic Inflammatory Disease or Disseminated Gonococcus
- Mucopurulent Cervicitis (most common presentation)
- Onset 5-10 days after exposure
- Odorless Vaginal Discharge (observed from os)
- Vaginal Bleeding or spotting (may present as Metrorrhagia)
- Friable Cervix bleeds easily
- Bartholin's gland inflammation
- Skene's gland inflammation
- Findings: Symptoms and Signs - Men (symptomatic in 90% of cases)
- Symptom onset within 2-6 days of exposure (may be delayed up to 30 days after exposure)
- Dysuria
- Epididymitis (unilateral Testicular Pain)
- Purulent discharge from Urethra meatus
- Findings: Symptoms and Signs - Disseminated Gonococcus (rare - occurs in <3% of patients)
- High fever may be present (variable)
- More common in pregnancy
- Dermatitis (75% of cases)
- Rash over trunk, extremities, palms and soles
- Present as Papules (bullae, Petechiae may be found)
- Necrotic Pustule ("gun metal gray") on red base over distal extremity (wrists, palms and soles)
- May progress into Hemorrhagic Pustules
- Usually less than 20 total lesions (typically 3 or less)
- Polyarticular Tenosynovitis
- Wrists and hands
- Ankles and feet
- Gonococcal Arthritis
- Aseptic Joint Aspiration does not rule-out Disseminated Gonococcus
- Endocarditis (rare)
- Meningitis (rare)
- Findings: Symptoms and Signs - Children
- Age >1 year
- Nearly always associated with sexual abuse
- Age <1 year (esp. day of life 2-5)
- Attributed to Vaginal Delivery
- Pharyngitis
- Neonatal Sepsis
- Scalp abscess (associated with fetal scalp electrode)
- Meningitis
- Arthritis
- Neonatal Conjunctivitis (Ophthalmia Neonatorum)
- Onset 6 days after exposure
- Conjunctival inflammation
- Mucopurulent Eye Discharge
- Evaluation
- Gram Stain of Conjunctival discharge for Gram Negative intracellular diplococci
- Gonococcal culture
- Prompt management prevents Globe Rupture or blindness
- Differential Diagnosis: Gonorrhea
- See Cervicitis
- See Vaginitis (or Vaginal Discharge)
- See Urethritis
- See Neonatal Conjunctivitis
- See Proctitis
- See Pharyngitis Causes
- See Polyarthritis
- Differential Diagnosis: Disseminated Gonococcal Infection
- Hypersensitivity Vasculitis
- Infective Endocarditis
- Korean hemorrhagic fever
- Meningococcemia
- Reiter's Syndrome
- Sweet's Syndrome
- (2005) Am Fam Physician 71(3):534-6 [PubMed]
- Complications
- Pelvic Inflammatory Disease (PID) in 10-20% of cases
- Fitz-Hugh Curtis Syndrome (rare)
- Perihepatitis syndrome that may present as right upper quadrant pain
- Systemic Gonorrhea
- Chronic Arthritis
- Neonatal Gonorrhea
- Gonorrheal Conjunctivitis
- Preterm Labor
- Endocarditis (rare)
- Meningitis (rare)
- Labs
- Nucleic Acid Amplification Test (DNA probe)
- Reliable alternative to culture (preferred for screening)
- Sample
- Men: Urethra or urine
- Women: Cervical swab is preferred
- Rapid: 30 minutes
- Test Sensitivity: 92-96%
- Test Specificity: 94-99%
- Gram Stain: Urethral or Cervical Smear
- Numerous White Blood Cells
- Gram Negative biscuit-shaped diplococci
- False PositiveGram Stain (saprophytic Neisseria)
- Gonorrhea Culture and Sensitivity
- Culture medium of chocolate agar or Martin-Lewis agar
- Required for Disseminated Gonococcus testing
- Blood Culture
- Throat Culture
- Synovial Fluid
- Screen all patient for concurrent STD
- Chlamydia (same DNA probe as for Gonorrhea)
- HIV
- Syphilis
- Diagnostic Studies
- Endoscopy in suspected Gonococcal Diarrhea
- Nonspecific findings limited to Rectum
- Biopsy and Culture show superficial exudates
- Management: Multi-Drug Resistance
- Antibiotics that are no longer effective against Gonorrhea
- Cefixime or Suprax
- http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm
- Not recommended as of 2012
- Ciprofloxacin and other Fluoroquinolones
- Penicillins
- Sulfanilamide
- Tetracyclines (including Doxycycline)
- Treatment of Gonorrhea in 2020 no longer requires dual therapy (due to rising resistance rates for other conditions)
- See management below
- Eradication typically requires Ceftriaxone 500 mg IM (1 gram IM/IV if weight > 150 kg, dose increased in 2020)
- Other agents may be considered
- Cefixime resistant strains are often also resistant to Doxycycline
- Risk of untreatable Gonorrhea is a real possibility
- Men who have Sex with Men have increased Azithromycin and Ceftriaxone MICs
- Kirkcaldy (2013) Ann Intern Med 158(5 Pt 1): 321-8 [PubMed]
- Gonorrhea treatment failures have exceeded 6% in Toronto, Canada
- Allen (2013) 309(2): 163-70 [PubMed]
- Rising MICs to all antibiotics against Gonorrhea may be a harbinger of untreatable Gonorrhea
- Bolan (2012) N Engl J Med 366(6): 485-7 [PubMed]
- Obtain standard cultures in patients returning with possible treatment failures
- Gonococcal Culture is required to evaluate for drug resistance and susceptibility
- DNA probes can not be used to determine Antibiotic Resistance
- Consider reinfection from insufficiently treated sexual partners (most common cause of "treatment failure")
- Consult infectious disease and public health department if multidrug resistance is suspected
- References
- Glauser (2014) Crit Dec Emerg Med 28(11): 2-10
- MMWR Morb Mortal Wkly Rep (1995) 44:761-5 [PubMed]
- Fox (1997) J Infect Dis 175: 1396-403 [PubMed]
- Management: Uncomplicated Gonorrhea
- Refer all sexual exposures for treatment
- See Pelvic Inflammatory Disease for that protoco
- Re-test for Gonorrhea (as well as Chlamydia and Trichomonas) again in 3 months after treatment (high risk of recurrence)
- Gonorrhea management
- Ceftriaxone 500 mg IV or IM for one dose (1 gram IM/IV if weight > 150 kg or 330 lb) OR
- Gentamicin 240 mg IM and Azithromycin 2 g orally for one dose OR
- Cefixime 800 mg orally once
- Alternative agent but NOT recommended due to Antibiotic Resistance
- Chlamydia management if not excluded (not indicated for Gonorrhea treatment without Chlamydia as of 2020)
- Chlamydia coninfection rates are 30-50%
- Doxycycline 100 mg twice daily for 7 days (preferred as of 2020 in non-pregnant patients) OR
- Azithromycin 1 g orally for 1 dose (in pregnant patients)
- Uncomplicated Gonorrhea in non-pregnant patient
- Azithromycin is no longer recommended for Gonorrhea managament if Chlamydia has been excluded
- Second agent (in addition to Azithromycin)
- Ceftriaxone 500 mg IM/IV for 1 dose (1 gram IM/IV if weight > 150 kg, dose increased in 2020)
- Cefotaxime 500 mg IM for 1 dose (not typically used, as Ceftriaxone is the standard treatment)
- Spectinomycin 2 g IM for 1 dose (not available in the United States, and resistance risk)
- Severe Cephalosporin allergy (e.g. Anaphylaxis or Toxic Epidermal Necrolysis)
- Gentamicin 5 mg/kg (<45 kg) up to 240 mg IM and Azithromycin 2 grams orally for 1 dose OR
- Gemifloxacin 320 mg orally and Azithromycin 2 grams orally for 1 dose
- Recheck for cure in 1-2 week
- Consult infectious disease
- Agents to avoid
- Cefixime (Suprax) 800 mg orally for 1 dose
- Not recommended due to increasing resistance in 2012 (see resistance above)
- If Cefixime is used due to lack of alternatives, then 800 mg dose is recommended
- Quinolones should no longer be used for Gonorrhea in U.S. due to high resistance
- Exception: Gemifloxacin with Azithromycin
- (2007) MMWR Morb Mortal Wkly Rep 56(14):332-6 [PubMed]
- Uncomplicated Gonorrhea in pregnant patient
- Ceftriaxone (Rocephin) 500 mg IM (1 gram IM/IV if weight > 150 kg or 330 lb) AND
- Azithromycin 2 grams PO for 1 dose
- Indicated for Cephalosporin resistance
- High-dose related GI intolerance is common
- One gram dose may not be effective for Gonorrhea
- Retest one week later to confirm clearance
- Older regimens that are no longer recommended
- Combined regimen 1 (not recommended due to Cefixime resistance; see above)
- Cefixime 800 mg PO for one dose and
- Erythromycin base 500 mg PO tid for 7 days
- Retest one week later to confirm clearance
- Amoxicillin 3 g PO AND Probenecid 1 gram orally
- Spectinomycin 2 g IM (if Penicillin allergic)
- High resistance (Cures only 52% of cases)
- Management: Non-Genital Gonorrhea
- Pharyngeal Gonorrhea
- Ceftriaxone 500 mg IM or IV for 1 dose (1 gram IM/IV if weight > 150 kg or 330 lb)
- Treat Chlamydia coinfection if not excluded (see above)
- Conjunctivitis due to Gonorrhea
- Ceftriaxone 1 gram IM or IV for 1 dose
- Meningitis due to Gonorrhea
- Ceftriaxone 1 to 2 grams IV every 12 hours for 10-14 days
- Endocarditis due to Gonorrhea
- Ceftriaxone 1 to 2 grams IV every 12 hours for 4 weeks or more
- Management: Disseminated Gonorrhea
- Do not use Quinolones for Gonorrhea in U.S. due to high resistance (see above)
- Parenteral Treatment Course
- Typical Course: 7 days
- Meningitis: 10-14 days
- Initial Inpatient dosing until symptoms improve for 24-48 hours
- CeftriaxoneSodium 1.0 g (50mg/kg) IV/IM every 24 hours or
- CefotaximeSodium 1.0 g (25 mg/kg) IV/IM every 8 hours or
- CeftizoximeSodium 1.0 g every 8 hours or
- Spectinomycin 2 grams IM every 12 hours
- Then followed by outpatient 7 day antibiotic course
- Cefuroxime axetil 500 mg twice daily or
- Cefixime 400 mg orally twice daily (not recommended due to resistance) or
- Amoxicillin 500 mg twice daily plus Probenecid 1 g/day
- Management: Children
- Urethral, cervical or pharyngeal
- Weight <45 kg
- Ceftriaxone 125 mg IM for a single dose
- Weight >45 kg
- Dose as for adults
- Bacteremia or Arthritis
- Ceftriaxone 50 mg/kg (up to 1 gram) IV or IM every 24 hours for 7 days
- Management: Newborns
- Asymptomatic infants born to mothers with untreated Gonorrhea
- Ceftriaxone 25-50 mg/kg (up to 250 mg) IV or IM for one dose OR
- Cefotaxime 100 mg/kg IV or IM for one dose
- Disseminated Gonorrhea or scalp abscess
- Ceftriaxone 25-50 mg/kg IV or IM every 24 hours for 7 days OR
- Cefotaxime 25-50 mg/kg IV or IM every 12 hours for 7 days
- Neonatal Meningitis
- Ceftriaxone 25-50 mg/kg IV or IM every 24 hours for 10 to 14 days OR
- Cefotaxime 25-50 mg/kg IV or IM every 12 hours for 10 to 14 days
- Ophthalmia Neonatorum
- Ceftriaxone 25-50 mg/kg (up to 250 mg) IV or IM for one dose
- Erythromycin 0.5% ophthalmic ointment is applied to each eye at birth in all newborns in U.S.
- Gonococcal Conjunctivitis risk is 30-40% without prophylaxis for infants born to positive mothers
- Gonococcal Conjunctivitis in Newborns is a high risk for blindness (even in first 24 hours)
- Management: Follow-up
- Test for reinfection at 3-6 months after treatment (Gonorrhea and Chlamydia)
- Regularly screen for other Sexually Transmitted Disease (e.g. HIV, Syphilis)
- Prevention
- Treat sexual partners of positive patients (within prior 60 days)
- Consider patient-delivered partner therapy
- See Expedited partner therapy (CDC recommendation if legal in practicing state)
- http://www.cdc.gov/std/ept
- Screen sexually active patients under age 26 years
- Consistent Condom use
- References
- Apgar (2003) AAFP Board Review, Seattle
- Mandell (2000) Infectious Disease, Churchill, p.2249-55
- (2000) AAP Redbook p. 254-60
- (1998) MMWR Morb Mortal Wkly Rep 47:1-115 [PubMed]
- (2015) MMWR Morb Mortal Wkly Rep 64(RR3):1-37 [PubMed]
- Cyr (2020) MMWR Morb Mortal Wkly Rep 69(50): 1911-6 [PubMed]
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- Mayor (2012) Am Fam Physician 86(10): 931-8 [PubMed]
- Miller (2000) Am Fam Physician 61(2):379-86 [PubMed]
- Yonke (2022) Am Fam Physician 105(4): 388-96 [PubMed]