Gonococcal Infections

Essentials of Diagnosis

• Purulent, profuse urethral discharge with dysuria, especially in men; yields positive gram-stained smear

• In men

  • Epididymitis

  • Prostatitis

  • Periurethral inflammation

  • Proctitis

  • Pharyngitis

• In women

  • Asymptomatic or cervicitis with purulent discharge

  • Vaginitis, salpingitis, proctitis also occur

• Disseminated disease

  • Fever

  • Rash

  • Tenosynovitis

  • Septic arthritis

• Nucleic acid amplification is preferred diagnostic test

General Considerations

• Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus

Demographics

• Gonorrhea is transmitted as a result of sexual activity; greatest incidence is in the 15- to 29-year-old age group

Symptoms and Signs

• Asymptomatic infection is common and occurs in both sexes

• Atypical sites of primary infection (eg, the pharynx or rectum) must always be considered

Urethritis

• In men

  • Initially, burning on urination and a serous or milky discharge

  • One to 3 days later, more pronounced urethral pain and the discharge becomes yellow, creamy, and profuse, sometimes blood tinged

  • May regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation

  • Rectal infection is common in men who have sex with men

• In women

  • Dysuria

  • Urinary frequency and urgency

Cervicitis

• Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination

• Infection often becomes symptomatic during menses

• Vaginitis and cervicitis with purulent discharge and inflammation of Bartholin glands are common

• Infection may remain as a chronic cervicitis

• It may progress to involve the uterus and fallopian tubes with acute and chronic salpingitis and ultimate scarring of tubes and sterility

• In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci

Conjunctivitis

• Direct inoculation of gonococci into the conjunctival sac occurs by autoinoculation from a genital infection or during childbirth

• The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly

Differential Diagnosis

• Nongonococcal urethritis, eg, Chlamydia, Ureaplasma urealyticum

• Septic arthritis of other bacterial cause

• Reactive arthritis

• Vaginal discharge due to candidiasis, bacterial vaginosis, or trichomoniasis

• Chronic meningococcemia

Laboratory Tests

• In men, Gram stain of urethral or rectal discharge, especially during the first week after onset, typically shows gram-negative diplococci within polymorphonuclear leukocytes

• Gram stain is less often positive in women

• Nucleic acid amplification tests

  • The preferred testing method for diagnosing all types of gonococcal infection due to its excellent sensitivity and specificity

  • Detects N gonorrhoeae in endocervical, vaginal, and urethral swab specimens and in urine

  • Can also detect N gonorrhoeae in oropharyngeal and rectal sites, although test is not FDA approved for these specimen types

  • Have largely replaced culture

• Cultures should still be obtained when evaluating a treatment failure to assess for antimicrobial resistance

Medications

• For uncomplicated infections of cervix, urethra, or rectum

  • Treatment of choice is ceftriaxone (250 mg intramuscularly) plus azithromycin (1000 mg orally as a single dose)

  • When an oral cephalosporin is the only option, cefixime, 400 mg orally as a single dose, can be combined with azithromycin as above but a "test of cure" culture or nuclear amplification test is recommend 1 week after treatment

  • When azithromycin is not an option, doxycycline at 100 mg orally twice daily for 7 days can be substituted

  • Spectinomycin, 1 g intramuscularly once, may be used for the penicillin-allergic patient (not currently available in the United States)

  • Fluoroquinolones are not recommended due to high rates of microbial resistance

• Pharyngeal gonorrhea also treated with ceftriaxone (250 mg intramuscularly) plus azithromycin (1000 mg orally as a single dose)

• Conjunctival gonorrhea is treated with ceftriaxone (1 g intramuscularly) plus azithromycin (1000 mg orally as a single dose)

• Pelvic inflammatory disease

  • Cefoxitin, 2 g parenterally every 6 hours, or cefotetan, 2 g intravenously every 12 hours plus doxycycline 100 mg every 12 hours

  • Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin, administered intravenously as a 2-mg/kg loading dose followed by 1.5 mg/kg every 8 hours

  • Ceftriaxone, 250 mg intramuscularly as a single dose (or cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally as a single dose,) plus doxycycline, 100 mg twice a day for 14 days, with or without metronidazole, 500 mg twice daily for 14 days, is an effective outpatient regimen

• Disseminated gonococcal infection (including arthritis and arthritis-dermatitis syndromes)

  • Ceftriaxone (1 g intravenously daily) plus azithromycin (1000 mg orally as a single dose), until 48 hours after improvement begins, at which time therapy may be switched to cefixime (400 mg orally daily) to complete at least 1 week of antimicrobial therapy

• Endocarditis

  • Ceftriaxone, 2 g every 24 hours intravenously, for at least 4 weeks

Therapeutic Procedures

• Therapy typically is administered before antimicrobial susceptibilities are known

• All sexual partners should be treated

Complications

Disseminated disease

• Systemic complications follow the dissemination of gonococci from the primary site via the bloodstream

• Skin lesions

  • Can range from maculopapular to pustular or hemorrhagic

  • Tend to be few in number and peripherally located

• Tenosynovitis is often found in the hands and wrists and feet and ankles

• Arthritis can occur in one or more joints and may be migratory

Prevention

• The condom, if properly used, can reduce the risk of infection

• Early treatment of contacts can halt the development of symptoms

When to Refer

• Report all cases to the public health department for tracing of contacts

When to Admit

• Most cases of pelvic inflammatory disease (perhaps not the mild cases)

• All cases of suspected or proven disseminated disease