1. California STD/HIV Prevention Training Center STD Clinical Series
Gonorrhea
California STD/HIV Prevention Training Center STD Clinical Series

2. Neisseria gonorrhoeae
Gram-negative diplococcus
Infects non-cornified epithelium
Second most common bacterial STD
Estimated >1 million US cases per year
Incidence highest among adolescents and young adults
Causes a range of clinical syndromes
Many infections are asymptomatic

3. History of GC
Neisseria gonorrhoeae described by Albert Neisser in 1879
Observed in smears of purulent exudates of urethritis, cervicitis, opthalmia neonatorum
Thayer Martin medium enhanced isolation of gonococcus in 1960
AKA “The Clap”

4. Risk Factors for GC Infection
Urban and low SES populations
Adolescents > age years > older
Black/Hispanic > White/API
Multiple sex partners
Inconsistent use of barrier methods
High prevalence in sexual network

5. GC Sexual Transmission
Efficiently transmitted by sexual contact
Greater efficiency of transmission from male to female
Male to female: %
Female to male: %
Vaginal & anal intercourse more efficient than oral
Can be acquired from asymptomatic partner
Increases transmission and susceptibility to HIV fold

6. GC Microbiology Gram-negative diploccocus
Infects non-cornified epithelium
Cervix
Urethra
Rectum
Pharynx
Conjunctiva
Observed intracellularly in PMNs on Gram stain

7. GC Pathogenesis
GC are ingested, evade host defenses, and spread through subepithelial tissues
Attachment mediated by pili
Divides every minutes
Leads to formation of submucosal abscesses and accumulation of exudate in lumen
GC toxins damage cells

8. Gonococcal Infections in Women
Cervicitis
Urethritis
Proctitis
Accessory gland infection (Skene, Bartholin)
Pelvic inflammatory disease (PID)
Peri-hepatitis (Fitz-Hugh-Curtis)
Pregnancy morbidity
Conjunctivitis
Many infections asymptomatic
Pharyngitis
DGI

9. Complications of GC Infections
in Women
Infertility
Ectopic Pregnancy
Chronic Pelvic Pain
Psychosocial
Upper Tract Infection
Local Invasion Systemic Infection
Genital Infection
Congenital Infection
HIV Infection

10. Gonococcal Cervicitis
Incubation 3-10 days
Symptoms:
Vaginal discharge
Dysuria
Vaginal bleeding
Cervical signs :
Erythema
Friability
Purulent exudate
STD Atlas, 1997

11. Pelvic Inflammatory Disease
Sx: lower abdominal pain
Signs: CMT, uterine/ adnexal tenderness, +/- fever
Laparoscopy may show hydrosalpinx, inflammation, abscess, adhesions
Adhesions
Tube
PID often silent
STD Atlas, 1997

12. Gonococcal Bartholinitis
Tender swollen Bartholin’s gland with purulent discharge
Infection at other sites common
STD Atlas, 1997

13. Bartholin’s Abscess Painful swollen Bartholin’s glands
Fluctuant, tender
May have expressible purulent discharge

14. Gonococcal Infections in Men
Urethritis
Epididymitis
Proctitis
Conjunctivitis
Abscess of Cowper’s/Tyson’s glands
Seminal vesiculitis
Prostatitis
Many infections asymptomatic
Pharyngitis
DGI
Urethral stricture
Penile edema

15. Gonococcal Urethritis
Incubation 2-7 days
Abrupt onset of severe dysuria
Purulent urethral discharge
Most urethral infections symptomatic
STD Atlas, 1997

16. Epididymitis Epididymitis Swollen painful epididymis Urethritis
Epididymal tenderness or mass on exam
STD Atlas, 1997

17. Gonococcal Infections in Women & Men
Urethritis
Proctitis
Pharyngeal infections
Conjunctivitis
Disseminated Gonococcal Infection

18. Gonococcal Ophthalmia in the Adult
Marked chemosis and tearing
Typically purulent discharge, erythema
STD Atlas, 1997

19. Gonococcal Ophthalmia in the Adult
Conjunctival erythema and discharge

20. Disseminated Gonococcal Infection
Gonococcal bacteremia
Sources of infection include symptomatic and asymptomatic infections of pharynx, urethra, cervix
Occurs in < 5% of GC-infected patients
More common in females
Patients with congenital deficiency of C7, C8, C9 are at high risk

21. DGI Clinical Manifestations
“Dermatitis-arthritis syndrome”
Arthritis: 90%
Characterized by fever, chills, skin lesions, arthralgias, tenosynovitis
Less commonly, hepatitis, myocarditis, endocarditis, meningitis
Rash characterized as macular or papular, pustular, hemorrhagic or necrotic, mostly on distal extremities

22. DGI Skin Lesion Necrotic, grayish central lesion on erythematous base
STD Atlas, 1997

23. DGI Skin Lesion Papular and pustular lesions on the foot
STD Atlas, 1997

24. DGI Skin Lesion Small painful midpalmar lesion on an erythematous base
STD Atlas, 1997

25. DGI Skin Lesion
Pustular erythematous lesions

26. DGI Skin Lesion
Papular erythematous skin lesion

27. DGI Differential Diagnosis
Meningococcemia
Staphylococcal sepsis or endocarditis
Other bacterial septicemias
Acute HIV infection
Thrombocytopenia & arthritis
Hepatitis B prodrome
Reiter’s Syndrome
Juvenile Rheumatoid Arthritis
Lyme disease

28. Gonococcal Complications in Pregnancy
Postpartum endometritis
Septic abortions
Post-abortal PID
Possible role in:
Gestational bleeding
Preterm labor and delivery
Premature rupture of membranes

29. Vertical Transmission and Neonatal Complications on Gonorrhea
Overall vertical transmission rate ~30%
Neonatal complications include:
Ophthalmia neonatorum
Disseminated gonococcal infection
(sepsis, arthritis, meningitis)
Scalp abscess (if fetal scalp monitor used)
Vaginal and rectal infections
Pharyngeal infections

30. Gonococcal Ophthalmia Neonatorum
Lid edema, erythema and marked purulent discharge
Preventable with ophthalmic ointment
STD Atlas, 1997

31. GC Infections in Children
Vulvovaginits
Urethritis
Proctitis
All cases should be considered possible evidence of sexual abuse
Culture should be obtained

32. GC Diagnostic Methods Gram stain smear Culture
Antigen Detection Tests: EIA & DFA
Nucleic Acid Detection Tests
Probe Hybridization
Nucleic Acid Amplification Tests (NAATs)
Hybrid Capture

33. Gonorrhea Diagnostic Tests
Sensitivity
90-95%
85-90%
80-95%
Specificity
 95%
 99%
 98%
Gram stain
(male urethra exudate)
DNA probe
Culture
NAATs *
* Able to use URINE specimens

34. GC Gram Stain In symptomatic male urethritis:
>95% sensitivity and specificity: reliable to diagnose and exclude GC
In cervicitis:
50-70%sensitivity, 95% specificity
Not useful in pharyngeal infections
Accessory gland infection: similar to male urethritis
Proctitis: similar to cervicitis

35. Gram Stain for GC: Urethral Smear
Numerous PMNs
Gram negative intracellular diplococci
STD Atlas, 1997

36. Gram Stain for GC: Cervical Smear
PMN with Gram negative intracellular diplococci
STD Atlas, 1997

37. GC Culture
Requires selective media with antibiotics to inhibit competing bacteria (Modified Thayer Martin Media, NYC Medium)
Sensitive to oxygen and cold temperature
Requires prompt placement in high-CO2 environment (candle jar, bag and pill, CO2 incubator)
In cases of suspected sexual abuse, culture is the only test accepted for legal purposes

38. GC Culture Candle Jar
STD Atlas, 1997

39. GC Culture Specimen Streaking Cervical and Urethral
STD Atlas, 1997

40. GC Culture After 24 Hours
STD Atlas, 1997

41. Gonorrhea Treatment Genital & Rectal Infections in Adults
Recommended regimens:
Cefixime 400 mg PO x 1 or
Ceftriaxone 125 mg IM x 1 or
Ciprofloxicin 500 mg PO x 1 or
Ofloxacin 400 mg PO x 1 or
Levofloxacin 500 mg PO x 1
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1 or
Doxycycline 100 mg PO BID x 7 d
All sex partners within past 60 days need evaluation and treatment
CDC 2002
Guidelines

42. Gonorrhea Treatment Genital & Rectal Infections in Adults
Alternative regimens:
Ceftizoxime 500 mg IM x 1
Cefotaxime 500 mg IM x 1
Cefoxitin 2 g IM x 1 plus probenecid 1 g PO x 1
Gatifloxacin 400 mg PO x 1
Lomefloxacin 400 mg PO x 1
Norfloxacin 800 mg PO x 1
Spectinomycin 2 g IM x 1
CDC 2002
Guidelines

43. Empiric Co-Treatment of CT Infections
Empiric co-treatment for chlamydia is cost effective if co-infection rate 20-40% and doxycycline used
Prevalence monitoring in California demonstrates that ~50% of GC cases are co-infected with CT
Consider testing rather than treating if local co-infection is low

44. Gonorrhea Treatment Extra-Genital Sites in Adults
Pharyngeal infection:
Ceftriaxone 125 mg IM x 1 or
Ciprofloxicin 500 mg PO x 1 or
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1 or
Doxycycline 100 mg PO BID x 7 d
Conjunctivitis:
Ceftriaxone 1 g IM x 1 dose
CDC 2002
Guidelines

45. Gonorrhea Treatment Pregnancy
Must avoid quinolones & tetracycline
Recommended regimens:
Cefixime 400 mg PO x 1
Ceftriaxone 125 mg IM x 1
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1 
Other appropriate chlamydial regimen
Test of cure in 3-4 weeks
CDC 2002
Guidelines
CalSTDCB 2001

46. Gonorrhea Treatment Neonates
Ophthalmia neonatorum prophylaxis:
Silver nitrate 1% aqueous solution topical x 1
Erythromycin 0.5% ointment topical x 1
Tetracycline 1% ointment topical x 1
Ophthalmia neonatorum treatment:
Ceftriaxone mg/kg IV or IM x 1 NTE 125 mg
NTE = not to exceed
CDC 2002 Guidelines

47. Gonorrhea Treatment Neonates
Prophylaxis for maternal GC infection:
Ceftriaxone mg/kg IV or IM x 1 NTE 125 mg
Disseminated Gonococcal Infection:
Ceftriaxone mg/kg/d IV or IM QD x 7 d (use 50 mg/kg/d for older children, treat for d if child weighs  45 kg)
Cefotaxime 25 mg/kg IV or IM q12h x 7 d
NTE = not to exceed
CDC 2002 Guidelines

48. Gonorrhea Treatment Children
Uncomplicated genital infection:
 45 kg: same as adults
 45 kg: ceftriaxone 125 mg IM x 1 (alternative spectinomycin 40 mg/kg IM x 1)
Disseminated Gonococcal Infection:
Ceftriaxone mg/kg/d x 7 d
Use 50 mg/kg/d for older children
Treat for 10-14d if child weighs  45 kg
CDC 2002
Guidelines

49. DGI Treatment Initial IV Therapy
Begin IV therapy for hrs, switch to oral therapy for a total of 1 week
Recommended regimen:
Ceftriaxone 1g IV or IM q 24 h
Alternative Regimens:
Cefotaxime 1 g IV q 8 h
Ceftizoxime 1 g IV q 8 h
Ciprofloxacin 400 mg IV q 12 h
Ofloxacin 400 mg IV q 12 h
Levofloxacin 250 mg IV q 24 h
Spectinomycin 2 g IM q 12 h
CDC 2002
Guidelines

50. DGI Treatment Subsequent Oral Therapy
Oral therapy for total treatment of 1 week:
Recommended Regimes:
Cefixime 400 mg PO BID
Ciprofloxacin 500 mg PO BID
Ofloxacin 400 mg PO BID
Levofloxacin 500 mg PO QD
CDC 2002
Guidelines

51. GC Antimicrobial Resistance
Resistance in 20%-30% of gonococcal isolates tested in U.S.
Plasmid mediated
B - Lactamase production
High-level tetracycline resistance
Chromosomal mediated
Confers resistance to PCN, tetracycline, spectinomycin, erythromycin, fluoroquinolones, and/or cephalosphorins

52. Use of Fluoroquinolones to Treat GC Infection
CipR GC up to 40% in Japan, Philippines, parts of SE Asia and the Pacific Islands
CipR in Hawaii over 10%
Antimicrobial resistance to fluoroquinolones increasing in the continental U.S., but still < 1%
Providers should get a travel history and if infection may have been acquired in Hawaii, Asia or the Pacific Islands, patient should be treated with a cephalosporin
Treatment failures should be cultured and tested for resistance (and re-treated)

53. CipR GC in California Prevalence of CipR GC in CA >10% in 2002
CA GC Tx Recommendations:
Avoid the use of fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin) to treat GC in California.
Use ceftriaxone 125mg IM x 1 to treat uncomplicated gonococcal infections of the cervix, urethra, and rectum
Note: cefixime is no longer being manufactured.

54. GC Patient Counseling Nature of transmission
Potential long term and neonatal complications
Abstain from sex for at least 3-4 days during treatment (7 days if co-treated for CT)
Warning signs and need for follow up
Notification and need for treatment of partners

55. GC Partner Management
All sex partners with contact during 60 days preceding the onset of symptoms or test date should be evaluated, tested & treated
If no sex partners in previous 60 days, treat the most recent partner

56. GC Prevention Strategies
Health promotion, education & counseling
Increased access to condoms
Early detection through screening in selected high risk populations
Effective diagnosis & treatment
Partner management
Risk reduction counseling

57. Gonorrhea Screening California Provisional Guidelines
Adolescent females from high prevalence areas
All patients with other STDs
MSMs with high risk behaviors
Pregnant women < 25 years old
Adolescents in juvenile halls

58. Gonorrhea Screening in Pregnancy
Screen in 1st trimester and again in 3rd trimester (~32 weeks) for high-risk or high prevalence patients
High risk includes new partners, multiple partners, non-mutually monogamous relationship, concurrent STDs
Higher prevalence among adolescents, urban, low SES, certain geographic areas