Gonorrhoea

Question 1

first line empirical treatment - gonorrhoea

Answer 1

Ceftriaxone 1gram IM

Question 2

treatment if antimicrobial sensitivity available for gonorrhoea

Answer 2

ciprofloxacin 500mg oral STAT (if isolate sensitive)

Question 3

within how many days of exposure should a person be offered epidemiological treatment

Answer 3

14 days

Question 4

Which organism causes gonorrhoea

Answer 4

Neisseria gonorrhoea

Question 5

During microscopy what would you expect to see on direct visualisation of N. gonorrhoea?

Answer 5

Monomorphic Gram negative diplococci (light pink colour) within polymorphonuclear leukocytes (PMNLs)

Question 6

Which CELLS in the body are implicated in gonorrhoea infection/transmission?

Answer 6

columnar epithelium-lined mucous membranes

Question 7

Which sites in the body does gonorrhoea infection occur?

Answer 7

primary sites of infection are the columnar epithelium-lined mucous membranes of the URETHRA, ENDOCERVIX, RECTUM, PHARYNX and CONJUNCTIVA

Question 8

Male infection - how many display symptoms?

Answer 8

90%

Question 9

Incubation period of gonorrhoea - time of exposure to infection to onset of symptoms?

Answer 9

2-5 days

Question 10

Female infection - most common symptom?

Answer 10

Increased or altered vaginal discharge

Question 11

Female infection - what proportion will have lower abdominal pain?

Answer 11

25% (however, pelvic and lower abdominal ten- derness is an uncommon examination finding in the absence of coinfection with Chlamydia trachomatis)

Question 12

What proportion of cisgender women with urogenital infection will also have rectal infection?

Answer 12

1/3 (a third)

Question 13

Secondary infection to other anatomical sites occurs through which 2 routes?

Answer 13

Transluminal spread from urethra or endocervix OR haematogenous dissemination from infected mucous membranes

Question 14

What complications can occur if there is transluminal spread? (3)

Answer 14

Epididymo-orchitis, prostatitis, PID

Question 15

Which complications occur from disseminated gonorrhoea?

Answer 15

skin lesions, arthralgia, arthritis, tenosynovitis. Rare - meningitis, endocarditis

Question 16

What 2 methods are used to detect N. gonorrhoea?

Answer 16

Nucleic acid amplification test (NAAT) or culture

Question 17

At what level of prevalence is routine testing recommended for gonorrhoea

Answer 17

Prevalence greater than or equal 1%

Question 18

At what level of prevalence would the majority of positive screening tests for gonorrhoea be false positive?

Answer 18

Prevalence <1%

Question 19

What is the sensitivity of microscopy for diagnosing gonorrhoea on urethral or meatal swabs with PENILE discharge? without penile discharge?

Answer 19

Penile discharge 90 - 95%; without symptoms 50-75%

Question 20

What is the sensitivity of microscopy for diagnosing gonorrhoea from ENDOCERVICAL samples?

Answer 20

37-50%

Question 21

What is the sensitivity of microscopy for diagnosing gonorrhoea from FEMALE urethral samples?

Answer 21

20%

Question 22

What is the sensitivity of cervical microscopy compared to nucleic acid amplification tests?

Answer 22

16%

Question 23

When should ano-rectal smears and microscopy be performed?

Answer 23

ONLY if rectal SYMPTOMS

Question 24

Nucleic acid amplification tests (NAATs) are recommended for extra-genital sites - what is their sensitivity?

Answer 24

> 95% in BOTH symptomatic and asymptomatic

Question 25

How does the sensitivity of NAAT on urine and urethral swab in cisgender men compare?

Answer 25

Equivalent sensitivity - first void urine preferred

Question 26

What is the recommended test for female samples for diagnosis of gonorrhoea?

Answer 26

NAAT of vulvovaginal swabs

Question 27

If a woman has had a hysterectomy, how might this alter your sampling site for gonorrhoea?

Answer 27

There is no evidence on optimal sampling site. Guidelines suggest urine and VVS for NAAT

Question 28

If a person has confirmed genital gonorrhoea, when should pharyngeal sampling be performed? Why?

Answer 28

Oropharygeal infection is more difficult to treat. Therefore, regardless of gender or reported sexual behaviour, test if: susceptibility results are not available and the infection may have been acquired in the Asia-Pacific region. This is because of high levels of antimicrobial resistance in that treat which may lead to treatment failure OR Genital infection with a confirmed ceftriax- one-resistant strain

Question 29

Following genital reconstruction surgery, what needs to be considered when assessing the susceptibility of a site to gonococcal infection?

Answer 29

The tissue used for reconstruction - sites constructed with MUCOSAL tissue are MORE SUSCEPTIBLE that sites constructed from skin

Question 30

How likely is gonococcal infection of the neopenis?

Answer 30

Rare

Question 31

What is the optimal genital testing site in transgender women?

Answer 31

Swab of neovagina and first void urine

Question 32

What is the optimal genital testing site in transgender men?

Answer 32

First void urine. If the vagina is still present, consider vulvovaginal swab also

Question 33

What proportion of patients with gonorrhoea also have concurrent infection with C. trachomatis?

Answer 33

19%

Question 34

List the 4 indications for gonorrhoea treatment?

Answer 34

1. Identification of intracellular Gram-negative diplo- cocci on microscopy 2. A positive culture for N. gonorrhoeae 3. A confirmed positive NAAT for N. gonorrhoeae 4. Sexual partner of confirmed case of gonococcal infection

Question 35

What percentage of gonorrhoea in the UK is resistant to ciprofloxacin?

Answer 35

36.4% (in 2017)

Question 36

Molecular testing on NAAT-positive gonorrhoea samples can be performed to identify susceptibility to ciprofloxacin - what does it test for?

Answer 36

gyrA gene mutations

Question 37

A lower dose of ceftriaxone would be adequate to treat the majority of gonococcal strains - why treat with a higher dose?

Answer 37

Ceftriaxone 1g is more effective against most isolates with increased MICs

Question 38

UK cases of gonorrhoea with resistance to both azithromycin and ceftriaxone were linked to which part of the World?

Answer 38

Asia-Pacific region

Question 39

What MIC level confers ceftriaxone resistance for gonorrhoea positive samples?

Answer 39

MIC >0.125mg/L

Question 40

What alternative treatment for gonorrhoea has Grade 1A evidence to support its use?

Answer 40

gentamicin 240mg IM WITH azithromycin 2gram oral

Question 41

What are the limitations of giving azithromycin alone for gonorrhoea treatment?

Answer 41

azithromycin 2g would not be effective against high level azithromycin-resistant isolates AND the GI side effects are poorly tolerated

Question 42

How long can low levels of azithromycin remain in the mucosal surfaces?

Answer 42

4 weeks

Question 43

What is the potential clinical implication if a person is re-infected within 4 weeks of treatment with azithromycin for gonorrhoea?

Answer 43

If re-infected and sub-MIC levels of azithromycin could result in azithromycin resistance.

Question 44

What other organisms may develop resistance if concurrent infection when treated by azithromycin for gonorrhoea?

Answer 44

Mycoplasma genitalium AND treponema pallidum

Question 45

Which anatomical sites may experience potential serious side effects with quinolone or fluoroquinolone use?

Answer 45

muscles tendons joints nervous system

Question 46

Which groups of people should you practice additional caution when prescribing quinolone or fluoroquinolone?

Answer 46

>60 yrs old corticosteroids (people on) Chronic kidney disease Organ transplantation

Question 47

What 3 alternative regimens for gonorrhoea treatment can be given with Grade 1B evidence?

Answer 47

CEFIXIME 400mg oral stat WITH azithromycin 2g oral SPECTINOMYCIN 2g im stat WITH azithromycin 2g oral Azithromycin 2g oral alone

Question 48

Why are alternative regimen for treatment of gonorrhoea not advised as monotherapy?

Answer 48

All alternative agents have been associated with TREATMENT FAILURE particularly PHARYNGEAL INFECTION and therefore should be given as DUAL therapy with azithromycin

Question 49

What is the treatment for gonococcal PID?

Answer 49

Ceftriaxone 1g IM stat AND standard PID treatment course

Question 50

What is the treatment for gonococcal epididymis-orchitis?

Answer 50

Ceftriaxone 1g IM stat AND standard EO treatment course

Question 51

What is the treatment for gonococcal conjunctivitis?

Answer 51

Ceftriaxone 1g IM stat AND saline irrigation of eye

Question 52

What is the treatment for gonococcal conjunctivitis, if there is history of penicillin anaphylaxis or cephalosporin allergy?

Answer 52

Lack of evidence. Treatment should be guided by antimicrobial susceptibility if available

Question 53

What is the treatment for disseminated gonococcal infection?

Answer 53

Treat for 7 days Ceftriaxone 1 g intramuscularly or intravenous every 24 hours or Cefotaxime 1 g intravenous every eight hours or Ciprofloxacin 500 mg intravenous every 12 hours (if the infection is known to be susceptible) or Spectinomycin 2 g intramuscularly every 12 hours

Question 54

When can you switch treatment for disseminated gonococcal infection from IV/IM to oral therapy?

Answer 54

24-48 hours after symptoms improve. Therapy should continue for total 7 days.

Question 55

following initial IV/IM therapy, What are the oral regimens for disseminated gonococcal infection?

Answer 55

Guided by sensitivities: CEFIXIME 400mg twice daily or CIPROFLOXACIN 500mg twice daily or OFLOXACIN 400mg twice daily

Question 56

quinolone or tetracycline antimicrobials should no be used in Pregnant and breastfeeding individuals. What treatment can they have?

Answer 56

Ceftriaxone 1g intramuscularly as a single dose or Spectinomycin 2 g intramuscularly as a single dose Azithromycin 2 g as a single oral dose (only if adequate alternatives are not available)

Question 57

When is epidemiological treatment recommend for contacts of gonorrhoea?

Answer 57

If presenting within 14 days of exposure, consider treatment

Question 58

A test of cure for all patients treated for gonorrhoea is recommended. Which patients in particular?

Answer 58

Persistent symptoms or signs Pharyngeal infection Treated with anything other than first line recom- mended regimen Infection acquired in the Asia-Pacific region

Question 59

What are the typical time-to-negative TOC for RNA NAATs and DNA NAATs respectively?

Answer 59

RNA NAAT = 7 days; DNA NAAT = 14 days

Question 60

What percentage is the performance standard expected for all BASHH auditable outcomes for gonorrhoea?

Answer 60

97%

Question 61

What must laboratories do before issuing a positive gonorrhoea result?

Answer 61

Ensure the result as been confirmed by supplementary testing

Question 62

When can an initial/first positive gonorrhoea result be accepted?

Answer 62

When the PPV is greater than or equal to 90%

Question 63

What antibiotic should be used in neonates for gonorrhoea treatment?

Answer 63

IV cefotaxime

Question 64

What age of neonate is ceftriaxone contraindicated for treatment of gonorrhoea?

Answer 64

<41 weeks postmenstrual age

Question 65

Why is ceftriaxone contraindicated in neonates <41 weeks postmenstrual age?

Answer 65

risk of precipitation in urine and lungs

Question 66

For children 2-12 yrs what is the treatment for gonococcal PID?

Answer 66

ceftriaxone 125mg IM then erythromycin 250mg BD and metronidazole weight adjusted for 2 weeks

Question 67

For children >12 yrs what is the treatment for gonococcal PID?

Answer 67

ceftriaxone 500mg IM + usual adult regimen