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Neisseria Gonorrhoeae
Gonorrhea Neisseria Gonorrhoeae
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Cause and Transmission
Caused by the bacterium Neisseria gonorrhoeae Sometimes called gonococcus Affects the male and female mucosa primarily but can affect other body areas such as skin, gums, tongue and the throat Mucosa is the lining of the genital organs 40% transfer from pregnant woman to her baby
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Background Galen Other names for this disease
A physician in early Rome first wrote about this disease He noticed a discharge from his patients and thought it was semen or Gonos Gonorrhea means the flow of seed Other names for this disease The clap Came from clappoir or the Parisian houses of prostitution in the middle ages From earliest history to modern times gonorrhea has been a major problem causing severe consequences like sterility, blindness and potentially death
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Background For almost 300 years syphilis and gonorrhea were thought to be the same disease The characteristic discharge of gonorrhea was considered to be the first symptoms of syphilis John Hunter, a physician in 1767 obtained pus from a patient with gonorrhea and injected himself Hunter fell victim to the effects of Syphilis and Gonorrhea since the pus was infected with both diseases He died from Syphilitic heart disease in 1793
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Lesson I: Epidemiology: Disease in the U.S.
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Background Many physicians considered Syphilis and Gonorrhea the same disease for the next 50 years
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Neisseria gonorrhoeae
Gram-negative diplococcus Infects non-cornified epithelium Cervix Urethra Rectum Pharynx Conjunctiva
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Neisseria gonorrhoeae
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
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Neisseria gonorrhoeae
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
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Incidence and Prevalence
Significant public health problem in U.S. Urban and low SES populations Adolescents > age years > older Black/Hispanic > White/API Multiple sex partners Increasing proportion of gonococcal infections caused by resistant organisms
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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 2-5 fold
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Gonorrhea — Rates: United States, 1970–2003 and the Healthy People 2010 target
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report
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Gonorrhea — Rates by state: United States and outlying areas, 2003
Note: The total rate of gonorrhea for the United States and outlying areas (Guam, Puerto Rico and Virgin Islands) was per 100,000 population. The Healthy People 2010 target is 19.0 cases per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report
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Gonorrhea — Rates by sex: United States, 1981–2003 and the Healthy People 2010 target
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report
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Gonorrhea — Rates by race and ethnicity: United States, 1981–2003 and the Healthy People 2010 target
Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population. Source: CDC/NCHSTP 2003 STD Surveillance Report
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Gonorrhea — Age- and sex-specific rates: United States, 2003
Source: CDC/NCHSTP 2003 STD Surveillance Report
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Risk Factors Multiple or new sex partners or inconsistent condom use
Urban residence in areas with disease prevalence Adolescents, females particularly Lower socio-economic status Use of drugs Exchange of sex for drugs or money
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Transmission Efficiently transmitted by: Male to female via semen
Female to male urethra Rectal intercourse Fellatio (pharyngeal infection) Perinatal transmission (mother to infant)
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Lesson II: Pathogenesis
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Microbiology Etiologic agent: Neisseria gonorrhoeae
Gram-negative intracellular diplococcus Infects mucus-secreting epithelial cells
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Gonorrhea: Gram Stain of Urethral Discharge
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
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Lesson III: Clinical Manifestations
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Asymptomatic Gonorrhea
Most infections are asymptomatic More women(75%) as asymptomatic than men (1%) Asymptomatic prevents elimination of this disease
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Symptomatic Gonorrhea
In women, Signs and Symptoms usually make their appearance after incubation of two weeks or longer Symptoms are frequently mild or nonspecific and can be overlooked Symptoms in women may include: Burning sensation upon urination Presence of unusual vaginal discharge Backache Vaginal bleeding Pain in lower abdomen
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Gonococcal Infections in Women
Cervicitis Inflammation of the cervix Urethritis Inflammation of the urethra Proctitis Inflammation of the rectum Accessory gland infection (Skene, Bartholin) Pelvic inflammatory disease (PID) Peri-hepatitis (Fitz-Hugh-Curtis) Pregnancy morbidity Conjunctivitis Many infections asymptomatic Pharyngitis DGI
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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
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Gonococcal Cervicitis
Incubation 3-10 days Symptoms: Vaginal discharge Dysuria Vaginal bleeding Cervical signs : Erythema Friability Purulent exudate Dysuria= painful urinatioA friable cervix during pregnancy is one that is prone to bleeding. The cervix is easily irritated, slightly inflamed and bleeds easily due to the increased blood flow. STD Atlas, 1997
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Cervicitis Non-specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding 50% of women with clinical cervicitis have no symptoms Incubation period unclear, but symptoms may occur within 10 days of infection
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Gonococcal Cervicitis
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
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Urethritis Symptoms: dysuria, however, most women are asymptomatic
40%-60% of women with cervical gonococcal infection may have urethral infection
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Complications in Women
Accessory gland infection Bartholin’s glands Skene’s glands Pelvic Inflammatory Disease (PID) Fitz-Hugh-Curtis Syndrome Perihepatitis
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Bartholin’s and Skene’s Glands
The Bartholin's glands (also called Bartholin glands or greater vestibular glands) are two pea sized glands located slightly posterior to the opening of the vagina. The glands secrete mucous to lubricate the vagina During sexual arousal, the Skene's gland becomes swollen with blood, stimulating nerve fibers associated with it. Ongoing stimulation of the area can produce an orgasm
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Gonococcal Bartholinitis
Tender swollen Bartholin’s gland with purulent discharge Infection at other sites common STD Atlas, 1997
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Bartholin’s Abscess Painful swollen Bartholin’s glands Tender
May have expressible purulent discharge
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Pelvic Inflammatory Disease (PID)
10 – 15% of gonorrhea cases have PID At times women may experience pain during sexual intercourse, sterility and ectopic pregnancy In ectopic pregnancy the fertilized egg is implanted outside of the uterus
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Pelvic Inflammatory Disease
Adhesions Sx: lower abdominal pain Signs: CMT, uterine/ adnexal tenderness, +/- fever Laparoscopy may show hydrosalpinx, inflammation, abscess, adhesions Tube The adnexa of uterus (or uterine appendages) are the structures most closely related structurally and functionally to the uterus. A hydrosalpinx is a distally blocked fallopian tube filled with clear fluid PID often silent STD Atlas, 1997
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Fitz-Hugh-Curtis Syndrom
Failure to diagnose PID can result in acute morbidity, including tuboovarian abscess, endometritis, Fitz- Hugh-Curtis syndrome (perihepatitis), and other chronic sequelae. Perihepatitis secondary to gonorrhea presents as right upper quadrant pain and nausea.
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Syndromes in Men and Women
Anorectal infection Pharyngeal infection Conjunctivitis Disseminated gonococcal infection (DGI)
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Symptomatic Gonorrhea
Signs and Symptoms in men appear 3 to 5 days after sexual intercourse with an infected partner Symptoms include: Burning sensation on urination Pus-like creamy white or yellow discharge from the penis
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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
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Male Urethritis Symptoms Asymptomatic in 10% of cases
Typically purulent or mucopurulent urethral discharge Often accompanied by dysuria Discharge may be clear or cloudy Asymptomatic in 10% of cases
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Gonococcal Urethritis
Incubation 2-7 days Abrupt onset of severe dysuria Purulent urethral discharge Most urethral infections symptomatic STD Atlas, 1997
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Gonococcal Urethritis: Purulent Discharge
Source: Seattle STD/HIV Prevention Training Center at the University of Washington: Connie Celum and Walter Stamm
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Epididymitis Epididymitis Swollen painful epididymis Urethritis
Epididymal tenderness or mass on exam Symptoms: Unilateral testicular pain and swelling STD Atlas, 1997
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Swollen or Tender Testicles (Epididymitis)
Source: Seattle STD/HIV Prevention Training Center at the University of Washington
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Gonococcal Infections in Women & Men
Urethritis Proctitis Pharyngeal infections Conjunctivitis Disseminated Gonococcal Infection
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Gonococcal Ophthalmia in the Adult
Marked chemosis and tearing Typically purulent discharge, erythema Chemosis is the swelling (or edema) of the conjunctiva. STD Atlas, 1997
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Gonococcal Ophthalmia in the Adult
Conjunctival erythema and discharge
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Chemosis
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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
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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
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DGI Arthritis Additional complications
Gonorrhea is the most common cause of arthritis in the adolescent. However, arthritis (septic or reactive) is a rare complication of this disease. Additional complications Corneal scarring after ocular gonococcal infections Destruction of cardiac valves in gonococcal endocarditis Death from congestive heart failure related to endocarditis Central nervous system (CNS) complications of gonococcal meningitis
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DGI Skin Lesion Necrotic, grayish central lesion on erythematous base
STD Atlas, 1997
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DGI Skin Lesion Papular and pustular lesions on the foot
STD Atlas, 1997
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DGI Skin Lesion Small painful midpalmar lesion on an erythematous base
STD Atlas, 1997
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DGI Skin Lesion Pustular erythematous lesions
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DGI Skin Lesion Papular erythematous skin lesion
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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
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Gonococcal Complications in Pregnancy
Postpartum endometritis Septic abortions Post-abortal PID Possible role in: Gestational bleeding Preterm labor and delivery Premature rupture of membranes
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Gonorrhea Infection in Children
Perinatal: infections of the conjunctiva, pharynx, respiratory tract Older children (>1 year): considered possible evidence of sexual abuse
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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
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Gonococcal Ophthalmia Neonatorum
Lid edema, erythema and marked purulent discharge Preventable with ophthalmic ointment STD Atlas, 1997
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GC Infections in Children
Vulvovaginits Urethritis Proctitis All cases should be considered possible evidence of sexual abuse Culture should be obtained
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Lesson IV: Diagnosis
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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
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Clinical Considerations
In cases of suspected sexual abuse Legal standard is culture with multiple tests to confirm the identity of Neisseria gonorrhoeae
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Gram Stain for GC: Urethral Smear
Numerous PMNs Gram negative intracellular diplococci PMN – Polymorphonuclear Antibodies STD Atlas, 1997
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Gram Stain for GC: Cervical Smear
PMN with Gram negative intracellular diplococci STD Atlas, 1997
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GC Culture Specimen Streaking Cervical and Urethral
STD Atlas, 1997
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GC Culture After 24 Hours STD Atlas, 1997
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Lesson V: Patient Management
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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
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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
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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
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Lesson VI: Prevention
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Screening Pregnancy A test for N. gonorrhoeae should be performed at the first prenatal visit for women at risk or those living in an area in which the prevalence of N. gonorrhoeae is high. Repeat test during the 3rd trimester for those at continued risk. Other populations can be screened based on local disease prevalence and patient’s risk behaviors.
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Partner Management Evaluate and treat all sex partners for N. gonorrhoeae and C. trachomatis infections if contact was within 60 days of symptoms or diagnosis. If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated. Avoid sexual intercourse until therapy is completed and both partners no longer have symptoms.
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Reporting Laws and regulations in all states require that persons diagnosed with gonorrhea are reported to public health authorities by clinicians, labs, or both.
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Patient Counseling/Education
Nature of disease Usually symptomatic in males and asymptomatic in females Untreated infections can result in PID, infertility, and ectopic pregnancy in women and epididymitis in men Transmission issues Efficiently transmitted Risk reduction Utilize prevention strategies
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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
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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
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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
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