STIs: Gonorrhea

Question 1

Gonorrhea – Neisseria gonorrhoeae Microbiology (3)

Answer 1

1. Etiologic agent: Neisseria gonorrhoeae
2. Gram‐negative intracellular diplococcus
3. Infects mucus‐secreting epithelial cells

Question 2

Gonorrhea Incidence (4)

Answer 2

1. Significant public health problem in U.S.
2. Number of reported cases underestimates incidence
3. Incidence remains high in some groups defined by geography, age, race/ethnicity, or sexual risk behavior
4. Increasing proportion of gonococcal infections caused by resistant organisms

Question 3

Gonorrhea Risk Factors (6)

Answer 3

1. Multiple or new sex partners or inconsistent condom use
2. Urban residence in areas with disease prevalence
3. Adolescents, females particularly
4. Lower socio‐economic status
5. Use of drugs
6. Exchange of sex for drugs or money

Question 4

Gonorrhea Transmission (6)

Answer 4

Efficiently transmitted by:

1. Male to female via semen
2. Female to male urethra
3. Rectal intercourse
4. Fellatio (pharyngeal infection)
5. Perinatal transmission (mother to infant)
6. Gonorrhea associated with increased transmission of and susceptibility to HIV infection

Question 5

Gonorrhea Manifestations in Men (8)

Answer 5

1. Urethritis – Inflammation of urethra
2. Symptoms (unlike Chlamydia)
3. Typically purulent or mucopurulent urethral discharge
4. Often accompanied by dysuria
5. Discharge may be clear or cloudy or green
6. Asymptomatic in 10% of cases
7. Incubation period: usually 1‐14 days for symptomatic disease, but may be longer
8. Epididymitis – Inflammation of the epididymis
   * Symptoms: unilateral testicular pain and swelling
   * Infrequent, but most common local complication in males
   * Usually associated with overt or subclinical urethritis

Question 6

Genital Infections in Women (3)

Answer 6

1. Most infections are asymptomatic
2. Cervicitis – inflammation of the cervix
3. Urethritis – inflammation of the urethra
   a. Symptoms: dysuria, however, most women are asymptomatic
   b. 40%‐60% of women with cervical gonococcal infection may have urethral infection

Question 7

Gonorrhea Complications in Women (6)

Answer 7

1. Accessory gland infection
2. Bartholin’s glands
3. Skene’s glands
4. Pelvic Inflammatory Disease (PID)
5. Fitz‐Hugh‐Curtis Syndrome
6. Perihepatitis

Question 8

Syndromes in Men and Women (4)

Answer 8

1. Anorectal infection
2. Pharyngeal infection
3. Conjunctivitis
4. Disseminated gonococcal infection (DGI)

Question 9

Gonorrhea Clinical Considerations with suspected sexual abuse

Answer 9

In cases of suspected sexual abuse: Legal standard is culture with multiple tests to confirm the identity of Neisseria gonorrhoeae in children.

Question 10

Recommended tx of uncomplicated gonorrhea of cervix, urethra, and rectum (3)

Answer 10

Ceftriaxone 250mg IM once

PLUS

Azithromycin 1g PO once

OR

Doxycycline 100mg PO 2x/day for 7 days

Question 11

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum: Alternative Regimens (3)

Answer 11

If ceftriaxone is not available:

1. Cefixime 400 mg orally in a single dose PLUS
2. Azithromycin 1 g orally in a single dose
3. In the case of azithromycin allergy, doxycycline (100 mg orally twice a day for 7 days) can be used in place of azithromycin as an alternative second antimicrobial when used in combination with ceftriaxone or cefixime

Question 12

Recommended tx of uncomplicated gonorrhea of pharynx (3)

Answer 12

Ceftriaxone 250mg IM once

PLUS

Azithromycin 1g PO once

OR

Doxyclin 100mg PO 2x/day for 7 days

Question 13

Gonorrhea Follow-Up (4)

Answer 13

1. A test-of-cure is not needed for persons who receive a diagnosis of uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens
2. Any person with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of cure using either culture or NAAT.
3. If the NAAT is positive, effort should be made to perform a confirmatory culture before retreatment.
4. All positive cultures for test-of-cure should undergo antimicrobial susceptibility testing.

Question 14

Gonorrhea Partner Management (4)

Answer 14

1. Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections if contact was within 60 days of symptoms or diagnosis.
2. If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated.
3. Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms.
4. Remember that the law varies from state to state and changes about expedited care for partners

Question 15

Gonorrhea Reporting (2)

Answer 15

1. Laws and regulations in all states require that persons diagnosed with gonorrhea are reported to public health authorities by clinicians, labs, or both.
2. State will call and want to know about the patient

Question 16

Gonorrhea patient counseling and education: nature of disease, transmission, risk reduction (4)

Answer 16

Nature of disease:

1. Usually symptomatic in males and asymptomatic in females
2. Untreated infections can result in PID, infertility, and ectopic pregnancy in women and epididymitis in men
3. Transmission issues: efficiently transmitted
4. Risk reduction: Utilize prevention strategies

Question 17

Gonorrhea Emerging Organisms with treatment implcaitions (3)

Answer 17

1. Other organisms have a role in PID …
2. Mycoplasma genitalium
   a. Recognized cause of urethritis
   b. Role in cervicitis and PID emerging
   c. No diagnostic test FDA cleared for use
   d. Nucleic acid amplification tests available in some large medical centers and commercial laboratories
   e. Suspect in persistent or recurrent urethritis and consider in persistent cervicitis and PID
3. Treatment implications
   a. Azithromycin > doxycycline
   b. Emerging resistance to azithromycin
   c. Moxifloxacin for recurrence