1. Tina McNutt

2. After this discussion the learner will be able to:  State the causative agent of the sexually transmitted infection (STI) gonorrhea  Explain the route of transmission of Neisseria gonorrhoeae  Assess conditions required for the establishment of infection by Neisseria gonorrhoeae  List the symptoms and treatment for gonorrheal infections  Analyze methods used to demonstrate the differential diagnosis of a Neisseria gonorrhoeae infection  Identify criteria that must be met in order to report “presumptive Neisseria gonorrhoeae” infection as well as methods for confirming identification  Evaluation test selection as it relates to cases of abuse  Conclude which populations are most at risk for infection  Propose possible options for the treatment of gonorrheal infections  Evaluate methods for the prevention of the spread of gonorrheal infection

3.  Neisseria gonorrhoeae 1  Gram-negative facultative bacterium measuring around 0.6-1.0 µm in diameter  Diplococci ▪ Arrange in pairs with a flattened side "coffee bean” shapes  Carbon dioxide needed for growth  Oxidase positive, non- endospore producer, motility negative  Optimal growth temperature of 35-37 o C http://neisseria.org/ng/

4.  Sexual transmitted infection spread through contact with the infected area of a sexual partner including the:  Penis, vagina, mouth, or anus  Perinatally from mother to baby during childbirth

5.  N. gonorrhoeae infects mucosal surfaces lined with columnar epithelium cells  Urethra  Cervix  Rectum  Pharynx  Conjunctiva of the eye http://textbookofbacteriology.net/themicrobialworld/gonorrhea.html Pili are used to attach to columnar epithelium cells Variable antigen for the pilin protein allow N. gonorrhoeae to evade the immune system

6.  May be asymptomatic  Urethral infection  Dysuria  White, yellow, or green urethral discharge  Complicated infection of epididymis may cause testicular or scrotal pain http://www.montrealstdclinic.com/gonorrhea.php

7.  Most are asymptomatic or have mild, nonspecific symptoms that may be mistaken for a bladder or vaginal infection  Possible symptoms include  Dysuria  Increased vaginal discharge  Bleeding between periods

8.  Rectal  May be asymptomatic  Discharge  Anal itching, soreness or bleeding  Painful bowel movements  Pharyngeal  Usually asymptomatic  Sore throat

9.  Conjunctivitis  Red eyes  Thick pus in the eyes  Swelling of the eyelids  Beginning about 2 to 4 days after birth  If left untreated may lead to blindness http://www.pediatricsconsultantlive.com/display/article/1803329/1383902

10.  Presumptive N. gonorrhoeae  Thayer-Martin growth  Gram negative diploccocci  Oxidase positive  Normal sexual site  12 or older  Confirmation  Rapid NH, Gonogen II, API Quad-Ferm+ http://www.thermoscientific.com/ecomm/servlet/productsdetail_11152___14787643_-1 Cases of sexual abuse – Require definitive, confirmed identification using at least two tests that involve different principles (e.g., biochemical, serological, or nucleic acid probe culture confirmation tests)

11.  Urogenital  Urethral specimen containing polymorphonuclear leukocytes (PMN) with intracellular Gram-negative diplococci  Urine or urethral specimen http://www.icgngo.org/GcinPMNs-GS-icg.JPG tested using nucleic acid amplification testing (NAAT), nucleic acid hybridization tests  Culture using Thayer Martin, Martin Lewis, or New York City media for susceptibility testing

12.  Urogenital  NAAT from urine, endocervical swab or vaginal swab specimen  Nucleic acid hybridization tests and cultures are done from endocervical swab specimens http://www.icgngo.org/GcinPMNs-GramStain-vigina_icg.jpg  Oral and/or anal infection  Pharyngeal and/or rectal swab specimens Culture or NAAT

13.  Gonorrhea is curable through treatment with antibiotics  If left untreated infection may lead to:  Males ▪ Epididymitis, prostatitis, or urethral stricture  Females ▪ Pelvic inflammatory disease  Sterility  Disseminated infection in rare cases ▪ Arthritis, endocarditis, meningitis  Individuals with gonorrhea are more susceptible to HIV infection

14.  After the U.S. gonorrhea control initiative was implemented in 1975 the incidence decreased by 74.3% from 1975 to 1997  Treatment of choice during this time was either penicillin and tetracycline  Resistances emerged and in 1993 recommended treatment was changed to cephalosporins and fluoroquinolones  Resistances to fluoroquinolones emerged and in 2007 cephalosporins became the recommended treatment

15.  Extended-spectrum cephalosporins ceftriaxone and cefixime are currently recommended as treatment  However, due to the development of resistance in Japan cefixime was taken off the list of recommend treatments in 2006  In 2011 Ohnishi and colleagues reported isolation of the first know high-level ceftriaxone resistant gonococcal strain (H041) from a sex worker in Japan (MIC of 2 μg/ml)

16.  Newly released clinical trial results from the CDC show two new treatment regimens  Injectable gentamicin with oral azithromycin  Oral gemifloxacin with oral azithromycin  Provides treatment options for those patients unable to tolerate ceftriaxone

17. http://www.cdc.gov/std/stats11/figures/30.htm

18.  Latex condoms can reduce the risk of acquiring gonorrhea  Prevention through abstinence from sexual intercourse or by maintaining a long-term mutually monogamous relationship with an uninfected partner  Currently there is no vaccine available

19. http://www.cdc.gov/std/stats11/figures/23.htm

20. http://www.cdc.gov/std/stats11/figures/22.htm

21.  Sexually active individuals  Sex with multiple partners  As of 2006 infection rates were 18 times higher among African Americans than among whites

22. References Conjunctivitis (Pink Eye) in Newborns. (2012, October 23). Retrieved July 6, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/conjunctivitis/newborns.html Dillon, J.-A. R. (2011, April 27). Neisseria gonorrhoeae. Retrieved July 6, 2013, from International Collaboration on Gonococci (ICG): http://www.icgngo.org/ Goldstein, E., Kirkcaldy, R. D., Reshef, D., Berman, S., Welnstock, H., Sabeti, P.,... Lipsitch, M. (2012, August). Factors Related to Increasing Prevalence of Resistance to Ciprofloxacin and Other Antimicrobial Drugs in Neisseria gonorrhoeae, United States. Emerg Infect Dis. 2012 August; 18(8):., 18(8), 1290–1297. Retrieved July 14, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414012/pdf/11-1202.pdf Gonorrhea - CDC Fact Sheet. (2013, February 13). Retrieved July 6, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea-detailed.htm Gonorrhea Laboratory Information Characteristics of N. gonorrhoeae and Related Species of Human Origin. (2011, August 8). Retrieved July 13, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/std/gonorrhea/lab/ngon.htm Long, K. S., & Manuselis, G. (2011). Neisseria Species and Morzxella catarrhalis. In C. R. Mahon, D. C. Lehman, G. Manuselis, & E. Wurm-Cutter (Ed.), Textbook of Diagnostic Microbiology (4th ed., pp. 376-394). Maryland Heights, MO: W.B. Saunders Company. NCHHSTP Newsroom. (2013, July 15). Retrieved July 22, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/nchhstp/newsroom/2013/Gonorrhea-Treatment-Trial-PressRelease.html Neisseria gonorrhoeae Home Page. (2007, April 26). Retrieved July 6, 2013, from Neisseria.org: http://neisseria.org/ng/ Ohnishi, M., Golparian, D., Shimuta, K., Saika, T., Hoshina, S., Iwasaku, K.,... Unemo, M. (2011, July). Is Neisseria gonorrhoeae Initiating a Future Era of Untreatable Gonorrhea?: Detailed Characterization of the First Strain with High-Level Resistance to Ceftriaxone. Antimicrobial Agents and Chemotherapy, 55(7), 3538-3545. doi:10.1128 Parham, P. (2009). Failures of the Body's Defenses. In P. Parham, The Immune System (pp. 332-333). New York: Garland Science, Taylr & Francis Group, LLC. Sexually Transmitted Diseases Treatment 2010 Guidelines: Gonococcal Infections. (28, January 2011). Retrieved July 13, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/std/treatment/2010/gonococcal- infections.htm Tigchlaar, H., Kannikeswaran, N., & Kamat, D. M. (2008, June 1). Gonococcal Conjunctivitis. Retrieved July 6, 2013, from PediatricsConsultantLive: http://www.pediatricsconsultantlive.com/display/article/1803329/1383902 Todar, K. (2009, December 31). The Microbial World: Gonorrhea. Retrieved July 13, 2013, from Textbook of Microbiology: http://textbookofbacteriology.net/themicrobialworld/gonorrhea.html