Gonococcal Disease

[Section Outline]

Description
Etiology

Author:

Roger M.Barkin

Description

Second most frequently reported sexually transmitted disease (STD) in the U.S.:
- Estimated 820,000 new cases per year
- <50% reported
- Highest rates in 15-24-yr-old males and females, as well as African Americans
- Increasing incidence in men who have sex with men (MSM):
  - Higher in HIV-positive individuals
- Humans only known host
Concurrent infection with Chlamydia trachomatis is common
Affects the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctiva
Urethritis most common presentation in men
Often asymptomatic in women

Etiology

Neisseria gonorrhoeae:

Gram-negative aerobic diplococci

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms
Essential Workup
Diagnostic Tests & Interpretation
Differential Diagnosis

Signs and Symptoms

Cervicitis:
- Defined as:
  - Mucopurulent endocervical discharge; OR
  - Easily induced endocervical bleeding
- Most common site of infection
- Up to 80% asymptomatic
- Most symptoms nonspecific:
  - Vaginal discharge
  - Menorrhagia
  - Pelvic pain
  - Dyspareunia
  - Frequency and dysuria
Pelvic inflammatory disease (PID):
- Up to 20% of untreated cases
- Lower abdominal pain - most common presenting symptom
- Other common signs and symptoms:
  - Dyspareunia, abnormal bleeding, abnormal cervical or vaginal discharge
- Symptoms often occur at onset of menses
- Fever (50%)
- 2/3 have mild, vague symptoms; may go unrecognized
- Fitz-Hugh-Curtis syndrome: (perihepatitis):
  - 4% occurrence rate
  - Most commonly associated with C. trachomatis
  - Right upper quadrant pain/tenderness
- Infertility may develop
Bartholin abscess
Urethritis:
- Incubation period 2-5 d
- Symptoms:
  - Penile discharge
  - Dysuria
Prostatitis - can occur in untreated urethritis
Epididymitis:
- Acute, unilateral testicular pain and swelling
Proctitis:
- Often asymptomatic
- Only site of infection in 40% of MSM
- Rectal infection occurs in 35-50% of women with endocervical infection
- 3-fold increase in HIV infection risk
- Symptoms:
  - Perianal pruritus, mucopurulent discharge, mild rectal bleeding, severe rectal pain, tenesmus, and constipation
Pharyngitis:
- Sore throat, exudative tonsillitis
Conjunctivitis:
- Primarily in newborns of infected child
- Autoinoculation in adults may occur
Disseminated gonococcal infections (DGI):
- Gonococcal bacteremia
- Arthritis: Dermatitis syndrome:
  - 0.5-3% of untreated mucosal infections
  - Triad of tenosynovitis, dermatitis, and polyarthralgia
  - Fever, chills, malaise
- Dermatitis:
  - Tender necrotic pustules on an erythematous base, few lesions, begin distally
- Acute monoarticular or oligoarticular arthritis:
  - Knee most common
  - Warm, erythematous joint with effusion and pain with range of motion
- Female > male, 3:1 ratio
  - Risk factors: Recent menstruation or recent pregnancy
- Rare manifestations:
  - Hepatitis
  - Myocarditis
  - Endocarditis
  - Meningitis

Physical Exam

Cervicitis:
- Cervical edema, congestion, friability
PID:
- Uterine tenderness, adnexal or cervical motion tenderness
Urethritis:
- Yellow-white thick discharge, urethral meatal erythema

Essential Workup

Clinical diagnosis in male gonorrhea:
- Gram stain 95% sensitive
Nucleic acid amplification test (NAAT) testing is common done if available
Cervical culture in female gonorrhea
Also test for chlamydia and syphilis. Consider HIV screening

Diagnostic Tests & Interpretation

Lab

NAATs:
- DNA or RNA sequences using polymerase chain reaction (PCR)
- Sensitivity for detection of N. gonorrhoeae in urogenital and nongenital anatomic sites is superior to culture but varies by NAAT type
- Many also test for chlamydia
- Useful in urethral, cervical, vaginal, and urine specimens
- Not routinely useful for rectal or oropharyngeal or conjunctival specimens
Cultures (gold stand ard):
- Thayer-Martin medium:
  - Mainstay for blood and synovial fluid
Gram stain:
- Intracellular gram-negative diplococci:
  - Approaches 100% sensitive in symptomatic men. Presence of polymorphonuclear leukocytes is supportive of diagnosis
Pharyngeal/rectal cultures for local symptoms in high-risk individuals
DGI:
- Synovial fluid analysis:
  - Neutrophilic leukocytosis, >50,000 cells/mm³
  - Positive cultures when >80,000 cells/mm³
- 2 or more sets of blood cultures
- Synovial, skin, urethral or cervical, and rectal cultures:
  - Thayer-Martin media
- Cerebral spinal fluid analysis may be indicated
PID/lower abdominal pain in female:
- CBC
- Urinalysis
- Pregnancy test
- Consider pelvic US for tubo-ovarian abscess
Rapid plasma reagin (RPR): For associated syphilis

Differential Diagnosis

Urethritis:
- Chlamydia
- Trichomonas
- UTI
- Syphilis
DGI:
- Bacterial arthritis:
  - Meningococcus (rash)
- Hepatitis B
- Connective tissue disease:
  - Reiter syndrome
  - Rheumatoid arthritis
  - Psoriatic arthritis
- Acute rheumatic fever:
  - Poststreptococcal arthritis
- Infective endocarditis
- Others:
  - HIV
  - Secondary syphilis
  - Viral infection
  - Lyme disease (rash)
  - Gout (arthritis)

Treatment ⬆ ⬇

ED Treatment/Procedures

Hydration (0.9% NS) for nausea/vomiting
Treat sexual partner. For expedited partner therapy jurisdiction - www.cdc.gov/std/ept
Patient with gonorrhea should generally be presumptively treated for chlamydial infection. Dual therapy is generally indicated to assure that different mechanisms are used as well as for additional coverage
Cervical, urethral, and anorectal infection:
- Ceftriaxone: 250 mg IM once OR
  - Cefixime has limited efficacy for pharyngeal gonorrhoeae
- Also treat for chlamydia:
  - Azithromycin: 1 g PO once OR
  - Doxycycline: 100 mg PO b.i.d for 7 d (less desirable because of multiple doses)
PID:
- Outpatient:
  - Ceftriaxone: 250 mg IM once or cefoxitin 2 g IM and probenecid 1 g PO once or another third-generation cephalosporin (ceftizoxime or cefotaxime) + doxycycline 100 mg PO b.i.d for 14 d with or without metronidazole 500 mg PO b.i.d for 14 d
- Inpatient:
  - Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + doxycycline 100 mg PO or IV q12h
  - Clindamycin 900 mg IV q8h + gentamicin loading dose (2 mg/kg) followed by (1.5 mg/kg) q8h or 3-5 mg/kg q24h
Pharyngitis:
- Ceftriaxone 250 mg IM single dose + treatment for chlamydia (azithromycin 1 g PO once)
Epididymitis:
- Ceftriaxone 250 mg IM once + doxycycline 100 mg b.i.d for 10 d
Treat sexual partner
DGI:
- Ceftriaxone: 1 g IV/IM daily (recommended); with azithromycin 1 g PO (once)
- Alternative (with azithromycin):
  - Cefotaxime: 1 g IV q8h plus
  - Azithromycin: 1 g PO; OR
  - Ceftizoxime: 1 g IV q8h plus
  - Azithromycin 1 g PO
- 24-48 hr after improvement, may switch to oral therapy for a total treatment course of at least 7 d with:
  - Cefixime: 400 mg PO b.i.d OR
  - Cefpodoxime: 400 mg PO b.i.d
- Neonates, incl gonococcal scalp abscess:
  - Ceftriaxone 25-50 mg/kg/d IV/IM for 7 d with duration of 10-14 d if meningitis present
  - If hyperbilirubinemia, cefotaxime 25 mg/kg q12h for 7 d; if meningitis, continue for 10-14 d
- Meningitis or endocarditis:
  - Ceftriaxone 1-2 g IV q12-24h for 10-14 d plus azithromycin as single dose
  - Treatment for endocarditis should be administered for at least 4 wk
Conjunctivitis:
- Adults:
  - Ceftriaxone 1 g IM once plus azithromycin and saline lavage of eye
- Ophthalmia neonatorum:
  - Ceftriaxone 25-50 mg/kg IM/IV once up to 125 mg
  - Saline irrigation, hospitalize
Meningitis/endocarditis:
- Ceftriaxone 1-2 g IV q12h plus azithromycin 1 g PO as single dose:
  - 10-14 d for meningitis
  - At least 4 wk for endocarditis
Severe cephalosporin allergy:
- Consult infectious disease
- Cephalosporin use postdesensitization best alternative
- Azithromycin 2 g PO for uncomplicated gonococcal infection:
  - Limit use to prevent resistance

Pediatric Considerations

Gonococcal ophthalmia neonatorum:
- Preventive therapy is erythromycin ophthalmic ointment, administered immediately after birth in all infants
- Mother with genital tract infection is source
- Bilateral conjunctivitis 2-5 d postpartum:
  - If untreated, leads to globe perforation
  - Treat with ceftriaxone 25-50 mg/kg IM/IV up to 125 mg
Neonates born to a mother with untreated N. gonorrhoeae infection in the absence of signs:
- Ceftriaxone 25-50 mg/kg IM/IV as single dose up to 125 mg
Children <45 kg with uncomplicated N. gonorrhoeae (vulvovaginitis, urethritis, pharyngitis)
- Ceftriaxone 25-50 mg IV up to 125 mg
Children >45 kg with uncomplicated infection
- Ceftriaxone 50 mg/kg IV up to 1 g (see adult)
Children <45 kg with bacteremia or arthritis:
- Ceftriaxone 50 mg/kg (up to 1 g) per day for 7 d
Children >45 kg with bacteremia or arthritis
- 1 g IM/IV per day for 7 d
Children found to have gonococcal infections should be tested for C. trachomatis, syphilis, and HIV. Screening should be done for potential abuse

Pregnancy Prophylaxis
Complications may include chorioamnionitis, prolonged rupture of membranes, preterm birth, low birth-weight infant, spontaneous abortion Transmission of N. gonorrhoeae to baby in 30-50% of cases Gonorrhea: Ceftriaxone 250 mg IM once and azithromycin 1 g PO once Spectinomycin is an alternative in allergic patients but is expensive and not produced in the U.S. Chlamydia: Erythromycin

Follow-Up ⬆ ⬇

Disposition

Admission Criteria

PID - CDC recommendations:

Severely ill (e.g., nausea, vomiting, and high fever)
Pregnant
Does not respond to or cannot take oral medication
Tubo-ovarian abscess
Other emergency surgical condition possible (e.g., appendicitis)
DGI

Discharge Criteria

Uncomplicated genital, pharyngeal, or conjunctival infection
Education essential related to getting tested routinely, contact evaluation and treatment, reduction of risky behaviors, and getting vaccinated to HPV
Follow-up is generally not needed in uncomplicated urogenital or rectal N. gonorrhoeae infections treated with recommended regimen

Issues for Referral

Infertility
Recurrent infection despite multiple appropriate therapy

Pearls and Pitfalls ⬆ ⬇

Epididymitis - rule out torsion
DGI - strongly consider in young sexually active patient with acute nontraumatic oligoarthritis or tenosynovitis

Additional Reading ⬆ ⬇

American Academy of Pediatrics. Red Book: 2018-2021 Report of the Committee on Infectious Diseases. 31st ed.Itasca, IL: American Academy of Pediatrics; 2018.
BachmanLH, JohnsonRE, ChangH, et al. Nucleic acid amplification tests for diagnosis of Neisseria gonorrhoeae oropharyngeal infections . J Clin Microbiol. 2009;47(4):902-907.
Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections . MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594. http://www.cdc.gov/mmwr/pdf/wk/mm6131.pdf.
Centers for Disease Control and Prevention. Recommendations for laboratory based detection of Chlamydia trachomatis and Neisseria gonorrhoeae 2014 . MMWR Recommend Rep2014;63(RR-02):1-19.
Centers for Disease Control and Prevention: Sexually transmitted disease surveillance, 2016. Atlanta, GA: U.S. Department of Health and Human Services, 2017.
Centers for Disease Control and Prevention. Gonorrhea - CDC Fact Sheet: CS115145, Content updated June 2012. Atlanta, GA: U.S. Department of Health and Human Services,http://www.cdc.gov/std/gonorrhea/gon-fact-sheet-june-2012.pdf.
MarrazzoJM, Hand sfieldHH, SparlingPF. Neisseria gonorrhoeae. In: Mand ell: Mand ell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed.2009.
WorkowskiKA, BolanGA; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015 . MMWR Recomm Rep. 2015;64(RR-03):1-137. http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

ICD9

098.0 Gonococcal infection (acute) of lower genitourinary tract
098.7 Gonococcal infection of anus and rectum
098.15 Gonococcal cervicitis (acute)
098.11 Gonococcal cystitis (acute)
098.10 Gonococcal infection (acute) of upper genitourinary tract, site unspecified
098.12 Gonococcal prostatitis (acute)
098.13 Gonococcal epididymo-orchitis (acute)
098.14 Gonococcal seminal vesiculitis (acute)
098.16 Gonococcal endometritis (acute)
098.17 Gonococcal salpingitis, specified as acute
098.19 Other gonococcal infection (acute) of upper genitourinary tract
098.1 Gonococcal infection (acute) of upper genitourinary tract
098.40 Gonococcal conjunctivitis (neonatorum)
098.6 Gonococcal infection of pharynx

ICD10

A54.00 Gonococcal infection of lower genitourinary tract, unsp
A54.03 Gonococcal cervicitis, unspecified
A54.6 Gonococcal infection of anus and rectum
A54.01 Gonococcal cystitis and urethritis, unspecified
A54.02 Gonococcal vulvovaginitis, unspecified
A54.09 Other gonococcal infection of lower genitourinary tract
A54.0 Gonococcal infection of lower genitourinary tract without periurethral or accessory gland abscess
A54.22 Gonococcal prostatitis
A54.24 Gonococcal female pelvic inflammatory disease
A54.29 Other gonococcal genitourinary infections
A54.31 Gonococcal conjunctivitis
A54.5 Gonococcal pharyngitis

SNOMED

17305005 acute gonorrhea of genitourinary tract (disorder)
42746002 Gonorrhea of rectum (disorder)
20943002 Acute gonococcal cervicitis (disorder)
236682002 Gonococcal urethritis (disorder)
186931002 Gonococcal anal infection (disorder)
197967000 Gonococcal prostatitis (disorder)
231858009 Gonococcal conjunctivitis (disorder)
236772009 Gonococcal epididymo-orchitis
240581006 gonococcal female pelvic infection (disorder)
74372003 Gonorrhea of pharynx (disorder)

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Basics ⬇