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Dip GUM > gonorrhoea > Flashcards

gonorrhoea Flashcards

1
Q

Describe the microbiology of gonorrhoea

A

Gonorrhoea is a gram negative intracellular diplococci bacteria

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2
Q

Where can gonorrhoea infect

A

gonorrhoea infects the columnar epithelium of any mucus membranes e.g. conjunctiva, pharyngeal, urethra, endocervix and rectum

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3
Q

What is the incubation period of gonorrhoea from the time of exposure to developing symptoms in men?

A

urethral symptoms usually present within 2-5 days following exposure

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4
Q

what are the most common symptoms of gonorrhoea in men

A

Mucopurulent urethral discharge

Dysuria without frequency

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5
Q

What are the most common symptoms women infected with gonorrhoea present with?

A

A change in their vaginal discharge (mucopurulent discharge)
dysuria without frequency
if progresses to PID - pelvic pain
rarely GC presents with IMB

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6
Q

How would rectal GC present

A

rectal discharge
change in bowel habit
tenesmus
rectal pain

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7
Q

If transluminal spread of GC occurs what conditions can result in men and women?

A

men- epididymo-orchtitis, prostatitis

women - PID

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8
Q

In a study conducted in the UK in women presenting with GC, what proportion were diagnosed with PID?

A

14%

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9
Q

What is the sensitivity of GC NAATs in men and women at urogenital sites?

A

> 95% sensitivity at urogenital sites

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10
Q

Are NAATs licences for extra-genital sites

A

No they are not licenced but they are recommended

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11
Q

What is the sensitivity of urethral microscopy used to detect GC in

a) symptomatic men?
b) asymptomatic men?

A

a) 90-95%

b) 50-75%

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12
Q

What is the sensitivity of endocervical microscopy used to detect GC in women?

A

a) 37-50%

(therefore female urethral and cervical microscopy is not routinely recommended)

a recent study reported it as low as 16%

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13
Q

What is the sensitivity of urethral microscopy used to detect GC in women?

A

20%

therefore female urethral and cervical microscopy is not routinely recommended

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14
Q

In women who have undergone a hysterectomy how should you test for GC?

A

VVS ct/gc NAAT and first catch urine CT/GC NAAT

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15
Q

In trans-female with a neo-vagina how should you test for CT/GC?

A

VVS NAAT + FCU NAAT

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16
Q

In trans-men with a neo-penis how should you test for GC?

A

first catch urine CT/GC NAAT

17
Q

When should you consider rectal and pharyngeal GC NAATs

A
  1. MSMs
  2. heterosexual females who are known contacts of GC, or those who have had a positive GC NAAT VVS
  3. heterosexual men and women tested positive for urogenital GC who may have acquired GC from asia-pacific regions (because of high levels of antimicrobial resistance)
  4. genital infection with confirmed ceftriaxone resistance
18
Q

what is the first line treatment option for GC when sensitivities are not known?
what is the grade of evidence?

A

Ceftriaxone 1 gram IM STAT (grade 1c)

19
Q

When culture sensitivities are known what is the first line treatment option for GC?

A

Ciprofloxacin 500mg stat, PO

20
Q

What was the reported level of ciprofloxacin resistance in the UK in 2017?

A

36.4% in 2017

21
Q

How many days following treatment for GC should patients be advised to abstain from having sex

A

7 days no sex following completion of antibiotic treatment and or until symptoms have resolved

22
Q

what is the window period for GC

A

2 weeks

23
Q

Partner Notification: What is the look back period for PN

a) symptomatic patients
b) asymptomatic patients
c) GC positive at extra-genital sites

A

a) 2 weeks symptomatic patients
b) 3 months asymptomatic patients
c) 3 months

24
Q

James comes to the clinic for treatment of confirmed GC, he tells you he last had sex 3 weeks ago with a CFP what advice should you give him regarding PN?

A

Offer to take partner details and contact directly or he may prefer to complete PN
Advise that they should be tested initially and only treated if positive. Partners within the last 2 weeks would be tested and treated empirically regardless of results.

25
Q

A patient reports a penicillin allergy and she has attended for GC treatment. Cultures show resistance to ciprofloxacin but sensitivities to azithromycin and ceftriaxone.
On further questioning she states when she last had amoxicillin as a child she had sickness and diarrhoea, but denies any breathing difficulties or rash.

How would you treat the GC?

A

Reassure the patient that 3rd generation cephalosporins are very safe in the context of penicillin allergy when no evidence of anaphylaxis. Therefore I would treat with CEFTRIAXONE 1 GRAM, IM STAT.

This is a much better option than azithromycin as reported failure rates is high due to antimicrobial resistance.

26
Q

In 2017 what was the prevalence of azithromycin resistance reported in the UK?

A

GRASP study: 9.2%

7.5% Euro-GASP 2016

27
Q

Name two reasons as to why we should avoid the use of azithromycin as a single agent in the treatment of GC?

A
  1. high levels of antimicrobial resistance

2. fears of accelerating the induction and spread of other STIs e.g. MGen and Syphilis

28
Q

What are the side effects of fluoroquinolones?

A
  1. CNS side effects (decrease seizure threshold)

2. Tendonopathy

29
Q

List the contra-indications of prescribing a fluoroquinolone

A
  1. patients aged > 60 years
  2. Renal impairment
  3. Concomitant use of corticosteroids
  4. Organ transplant patients

all these factors increase risk of tendinitits/tendo damage (note tendinopathy can occur within 48 hours of starting Rx)

30
Q

List four alternative treatment options for GC excluding ceftriaxone and azithromycin

A
  1. Azithromycin 2 gram, PO STAT (avoided as high levels of treatment failure due to resistance)
  2. Aztiromycin 2gram, PO STAT + cefixime 400mg PO STAT ( low levels resistance reported in UK)
  3. Azithromycin 2 gram, PO STAT + gentamicin 240mg IM STAT ( RCT - 100% clearance however few extra-genital GC infections included)
  4. Azithromycin 2 gram, PO STAT + spectinomycin 2grams IM STAT ( not recommended in pharyngeal infections due to poor efficacy)
31
Q

What are the treatment options for disseminated GC?

A
  1. Ceftriaxone 1G IM or IV
  2. Cefotaxime 1G, IV, TDS
  3. Ciprofloxacin 500mg, IV, BD
  4. Spectinomycin 2g, IM BD

consider oral switch after 24-48 hours

32
Q

A patient has been treated with ceftriaxone 1 gram, OD IM for the last 48 hours for disseminated GC. Their inflammatory markers are much improved, and they have been apyrexial for the last 24 hours. What are the options for oral switch assuming sensitivities are known and no resistance is noted.

A

a) Cefixime 400mg BD
b) Ciprofloxacin 500mg BD
c) Ofloxacin 400mg BD

complete total of 7 day course of antibiotics, TOC at 2 weeks, ensure PN and no sex until partner completed Rx

33
Q

Jasmine is 12 weeks pregnant, she went to see her midwife and mentioned a new vaginal discharge. VVS for CT/GC has demonstrated GC. She attends your sexual health clinic. She is allergic to penicillin with Stevens-Johnson reaction previously requiring ITU admission. She is otherwise fit and well.

How would you treat the GC and what other advice would you give Jasmine?

A

Need to avoid ceftriaxone due to history of SJS
she needs to be offered triple site swabs and cultures to check for sensitivities - await culture results before Rx in this case as she is early on in the pregnancy
options for treatment would be:
1. spectinomycin 2 gram IM, stat - category B by the FDA in pregnancy - not known to be harmful and can be used if no other alternative options, caution when used in BF mothers as no known if is excreted in breast milk (1B)
2. azithromycin 2 gram PO stat, - only used if sensitivities are known (1B - high rates of Rx failure)

Personally in pregnancy I would wait for sensitivities before offering treatment.
PN - advise any regular partners within the last 2 weeks need testing and empirical treatment
No sex until TOC (technically guidelines are 7 days)
TOC at 2/52

(BASHH guideline doesn’t discuss gentamicin - but bnf states avoid as can cause auditory and vestibular damage to the neonate when used in second and third trimester)

34
Q

Jasmine is worried about the risk of gonorrhoea on her pregnancy, what would your advice be?

A

It is very important to treat gonorrhoea during pregnancy.

The risks of not treating the gonorrhoea are much higher than the risks of treating. This includes the risk of preterm labour, risk of miscarriage, risk of low birth weight and stillbirth.

Although no studies have been conducted on the use of antibiotics in pregnancy we have been treating gonorrhoea with these antibiotics during pregnancy for a long time and they have been extremely safe.

35
Q

At what time interval should a TOC be performed following treatment for positive GC

a) if RNA NAAT
b) if DNA NAAT

A

a) 7 days

b) 14 days

36
Q

When should more emphasis be placed on performing a TOC in patients treated for GC

A
  1. pregnancy
  2. when first line treatment options could not be used and thus much higher reports of treatment failure
  3. pharyngeal infection (higher reports of treatment failure)
  4. persistent symptoms or signs
  5. patients who acquired infection in the asia-pacific region where antimicrobial susceptibility is unknown
37
Q

What tests should be performed for TOC in an asymptomatic female who had GC +ve on pharyngeal and VVS NAAT, rectal NAAT -ve?

A

offer pharyngeal and VVS NAAT at TOC, if rectal NAAT originally was -ve no need to repeat
only do culture if NAAT subsequently comes back positive
in a symptomatic patient at the time of TOC offer NAAT + cultures

38
Q

If a TOC returns back positive following treatment for GC with ceftriaxone; when sensitivities were known and no sex has occurred in the treatment period.
Where should the clinician report these results

A

Inform public health england of any possible ceftriaxone treatment failures

Dip GUM (23 decks)

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