Gonorrhea

California STD/HIV Prevention Training Center

STD Clinical Series
 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

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

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
Efficiently transmitted by sexual contact
Greater efficiency of transmission from male
to female
Maleto 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
Gram-negative diploccocus
Infects non-cornified epithelium
Cervix
Urethra
Rectum
Pharynx
Conjunctiva

Observed intracellularly in PMNs on

Gram stain
 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

Cervicitis Pharyngitis

Urethritis DGI

Proctitis
Accessory gland infection (Skene, Bartholin)
Pelvic inflammatory disease (PID)
Peri-hepatitis (Fitz-Hugh-Curtis)
Pregnancy morbidity
Conjunctivitis
Many infections asymptomatic
 Complications of GC Infections
in Women

Upper Tract Infertility

Infection Ectopic Pregnancy
Chronic Pelvic Pain
Psychosocial
Local Invasion
Genital
Systemic Infection
Infection

Congenital Infection

HIV Infection
Gonococcal Cervicitis
Incubation 3-10 days
Symptoms:

Vaginal discharge
Dysuria
Vaginal bleeding
Cervical signs :

Erythema
Friability
Purulent exudate

STD Atlas, 1997

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

Tender swollen
Bartholins gland
with purulent
discharge
Infection at other
sites common

STD Atlas, 1997

Bartholins
Abscess
Painful swollen
Bartholins glands
Fluctuant, tender
May have
expressible
purulent discharge
Gonococcal Infections in Men

Urethritis Pharyngitis

Epididymitis DGI

Proctitis Urethral stricture

Conjunctivitis Penile edema

Abscess of Cowpers/Tysons glands

Seminal vesiculitis
Prostatitis
Many infections asymptomatic
Gonococcal Urethritis

Incubation 2-7
days
Abrupt onset of
severe dysuria
Purulent urethral
discharge
Most urethral
infections
STD Atlas, 1997 symptomatic
Epididymitis Epididymitis

Swollen painful
epididymis
Urethritis
Epididymal
tenderness or
mass on exam

STD Atlas, 1997

Gonococcal Infections in
Women & Men
Urethritis
Proctitis
Pharyngeal infections
Conjunctivitis
Disseminated
Gonococcal Infection
Gonococcal Ophthalmia
in the Adult
Marked
chemosis
and
tearing
Typically
purulent
discharge,
erythema
STD Atlas, 1997
Gonococcal Ophthalmia
in the Adult
Conjunctival
erythema
and
discharge
 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
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
Necrotic,
grayish
central lesion
on
erythematous
base

STD Atlas, 1997

 DGI Skin Lesion
Papular and
pustular
lesions on
the foot

STD Atlas, 1997

 DGI Skin Lesion
Small painful
midpalmar
lesion on an
erythematous
base

STD Atlas, 1997

 DGI Skin
Lesion

Pustular
erythematous
lesions
DGI Skin Lesion

Papular
erythematous
skin lesion
 DGI Differential Diagnosis
Meningococcemia
Staphylococcal sepsis or endocarditis
Other bacterial septicemias
Acute HIV infection
Thrombocytopenia & arthritis
Hepatitis B prodrome
Reiters Syndrome
Juvenile Rheumatoid Arthritis
Lyme disease
 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
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
Lid edema,
erythema and
marked
purulent
discharge
Preventable
with
ophthalmic
ointment
STD Atlas, 1997
 GC Infections in Children

Vulvovaginits
Urethritis
Proctitis
All cases should be considered
possible evidence of sexual abuse
Culture should be obtained
 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
Sensitivity Specificity
Gram stain 90-95% 95%
(male urethra exudate)
DNA probe 85-90% 95%
Culture 80-95% 99%
NAATs * 90-95% 98%

* Able to use URINE specimens

 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
Numerous
PMNs
Gram negative
intracellular
diplococci

STD Atlas, 1997

Gram Stain for GC: Cervical
Smear
PMN with
Gram negative
intracellular
diplococci

STD Atlas, 1997

 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

STD Atlas, 1997

GC Culture Specimen Streaking
Cervical and Urethral

STD Atlas, 1997

GC Culture After 24 Hours

STD Atlas, 1997

 Gonorrhea Treatment
Genital & 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 CDC 2002
Guidelines
Doxycycline 100 mg PO BID x 7 d
All sex partners within past 60 days need
evaluation and treatment
 Gonorrhea Treatment
Genital & 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 CDC 2002
Guidelines
Spectinomycin 2 g IM x 1
 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

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
CDC 2002
Conjunctivitis: Guidelines
Ceftriaxone 1 g IM x 1 dose
 Gonorrhea Treatment
Pregnancy
Must avoid quinolones & tetracycline
Recommended regimens:
Cefixime 400 mg PO x 1
Ceftriaxone 125 mg IM x 1
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1
CDC 2002
Other appropriate chlamydial regimen
Guidelines

Test of cure in 3-4 weeks

CalSTDCB 2001
 Gonorrhea Treatment
Neonates

Ophthalmia neonatorum prophylaxis:

Silvernitrate 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
Neonates

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

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 CDC 2002
Use 50 mg/kg/d for older children Guidelines
Treat for 10-14d if child weighs 45 kg
 DGI Treatment
Initial 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 CDC 2002
Ofloxacin 400 mg IV q 12 h
Guidelines
Levofloxacin 250 mg IV q 24 h
Spectinomycin 2 g IM q 12 h
 DGI Treatment
Subsequent 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
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
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
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

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

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
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

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

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