Gonorrhea. Pharyngeal gonorrhea. THE ENEMY: Neisseria Gonorhheae

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1 Gonorrhea THE ENEMY: Neisseria Gonorhheae FUSSY gram positive diplococcus Pathogen ONLY of humans Increases transmission of HIV FIVEFOLD! About 700,000 cases yearly in the USA 1 in 5 males get GC with 1 exposure Half of females get GC with 1 exposure Oral sex and rectal sex also efficient in transmission Pharyngeal gonorrhea 1

2 Who is most likely to get GC? Females age cervical ectopy - multiple partners - lack of protection - lack of access to health care - older partners Non-Hispanic Blacks Residents of inner cities Concept of core group of transmitters Important factoids Majority of STI s may be asymptomatic Targeted screening of women is recommended Rescreen at 3 months after treatment for reinfection CDC recommends yearly screening of all sites of exposure for MSM s (2/3 of MSM s have GC outside genital area) N. gonorrhea: weaponry Adherence to mucosal epithelium (Pili, outer membrane proteins Penetration to submucosal tissue (cytokine release) Submucosal microabscesses from WBC s Gonococcal exotoxin destroys ciliated cells in fallopian tubes No antibody protection against multiple infections PID/tubo-ovarian abscess Spread of PID 2

3 Abscess Gonococcalinfection GC: the enemy invades Epithelial cell landing sites: Conjunctiva Pharynx Urethra Endocervix Rectum Gonococcal epididymitis If untreated GC: common clinical outcome Males - asymptomatic - days - mucopurulent discharge worse in 1-2 d Females - vaginal discharge -dysuria - abdominal pain (PID) - intermenstrual bleeding - cervix can have mucopurulent discharge Other common sites include pharynx, rectum 3

4 Gonococcal urethritis Vulnerable victims: neonates Maternal cervical infection: 30% risk GC ophthalmia neonatorum: 2-5 d incubation Clinical findings: - Bilateral eyelid edema - Chemosis - Copious purulent discharge Complications: - Mild chronic infection for months - Ulceration, globe perforation - Panophthalmitis - Blindness Gonococcal conjunctivitis Disseminated GC (complement dficiency common: 13%) Dermatitis: - discrete tender necrotic pustules on red bases - located distally on upper extremities Migratory polyarthralgia or tenosynovitis: - early finding - affects smaller joints Pyogenic arthritis - occurs later in course - can be mono or polyarticular - likes wrists, MCP, ankle or knee joints Rare complications - endocarditis usually aortic valve, rapidly proressive - hepatitis - meningitis 4

5 Gonococcal rash Disseminated gonorrhea Identifying the Enemy: testing for GC Gram stain: intercellular gram neg diplococci fron eye, male urethra etc. Gonococcal arthritis Culture (critical for resistant strains): - inoculate STAT on chocolate agar, Thayer-Martin martin-lewis media - incubate at degrees C, 4-6% CO2, high humidity 5

6 Testing for GC: NAAT testing What are NAATS? (nucleic acid amplification tests) They are used to amplify small amounts of DNA or RNA in test samples Amount of DNA or RNA in sample is increased usung PCR or LCR (polymerase chain or ligase chain rections) The sample is probed with artificially produced complementary strands of DNA or RNA used to detect a unique portion of the genome N. gonorrhoeae: the implacable enemy, a historical record 1936: Sulfanilimides used 1946: penicillin was treatment of choice 1976: Penicillinase producing N. gonorrhoeae appears 1985: much resistance to tetracyclines so ceftriaxone usage begun 1989: penicillin completely ineffectual, go to drug is now ceftriaxone 125 mg IM 1991: fluoroquinolone resistant N. gonorrhoeae in the 50 th state N. Gonorrhoeae: a losing battle 1996: fluoroquinolone resistance predominates in Hawaii 2002: don t treat with fluoroquinolones in California or Hawaii 2004: Don t treat men who have sex with men with fluoroquinolones 2007: No-one should be treated with fluoroquinolones Now: ceftriaxone dose has been doubled to 250 mg IM which is almost 100% aactive against both genital and extragenital gonorrhea N. Gonorrhea: the state of the conflict Cefixime is no longer recommended for treatment MIC s of ALL cephalosporins is increasing Gonococcal Isolate Surveillance Project: 30 sites across country do GC susceptibility testing Expedited partner therapy (EPT) varies from state to state 6

7 CDC recommendations Duel therapy: Ceftriaxome + doxycycline x 1 wk OR Ceftriaxone for a week + 1 g azithromycin BUT Cefixime is second line drug SO Use 400 mg cefixime and either doxycycline or azithromycin What if the patient is allergic? Allergic to penicillin and ceftriaxone: give2 g azithromycin BUT 25% will have nausea/vomiting within hour Recommendation: Give something to eat 15 min prior Observe for an hour afterwards Try powder form of azithromycin Regimens other than ceftriaxone Test of cure in 1 week NAATS or culture If test of cure at 1 week shows gonorrhea, ask if patient had sex within the week If no sex, manage as treatment failure: - repeat test of cure, with GC culture - treat with ceftriaxone and 2 g azithromycin if cefixime was used - If ceftriaxone was initial drug, consult ID specialist and REPORT (health dept) Criteria for cephalosporin resistance Laboratory confirmed infection with N. gonorroeae Patient got cephalosporin-based treatment advised by CDC Patient NOT re-infected Lab criteria for cephalosporin resistance based on MIC (mean inhibitory concentration or concentration of antibiotic in test tube which prevents organism growth) 7

8 Test of Cure Retest at 3 months if one week test is negative Retest at 3 months if cefttriaxone regimen was used Expedited partner therapy (EPT) Know your state laws Partner packs: cefixime 400mg + azithromycin 1 g Can be used if no other way of getting partner treated The future Gentamycin 5 mg/kg IM as single dose Carbapenems (ertapenem IM ) There are few other choices!!!! 8

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