1. Neisseria Gonorrhoeae
Gonorrhea
Neisseria Gonorrhoeae

3. 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

4. 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

5. 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

6. Lesson I: Epidemiology: Disease in the U.S.

7. Background
Many physicians considered Syphilis and Gonorrhea the same disease for the next 50 years

8. Neisseria gonorrhoeae
Gram-negative diplococcus
Infects non-cornified epithelium
Cervix
Urethra
Rectum
Pharynx
Conjunctiva

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Gonorrhea — Age- and sex-specific rates: United States, 2003
Source: CDC/NCHSTP 2003 STD Surveillance Report

18. 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

19. Transmission Efficiently transmitted by: Male to female via semen
Female to male urethra
Rectal intercourse
Fellatio (pharyngeal infection)
Perinatal transmission (mother to infant)

20. Lesson II: Pathogenesis

21. Microbiology Etiologic agent: Neisseria gonorrhoeae
Gram-negative intracellular diplococcus
Infects mucus-secreting epithelial cells

22. Gonorrhea: Gram Stain of Urethral Discharge
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

23. Lesson III: Clinical Manifestations

24. Asymptomatic Gonorrhea
Most infections are asymptomatic
More women(75%) as asymptomatic than men (1%)
Asymptomatic prevents elimination of this disease

25. 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

26. 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

27. 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

28. 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

29. 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

30. Gonococcal Cervicitis
Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

32. Urethritis Symptoms: dysuria, however, most women are asymptomatic
40%-60% of women with cervical gonococcal infection may have urethral infection

33. Complications in Women
Accessory gland infection
Bartholin’s glands
Skene’s glands
Pelvic Inflammatory Disease (PID)
Fitz-Hugh-Curtis Syndrome
Perihepatitis

34. 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

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

37. Bartholin’s Abscess Painful swollen Bartholin’s glands Tender
May have expressible purulent discharge

40. 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

41. 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

42. 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.

43. Syndromes in Men and Women
Anorectal infection
Pharyngeal infection
Conjunctivitis
Disseminated gonococcal infection (DGI)

44. 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

45. 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

46. 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

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

48. Gonococcal Urethritis: Purulent Discharge
Source: Seattle STD/HIV Prevention Training Center at the University of Washington:
Connie Celum and Walter Stamm

50. Epididymitis Epididymitis Swollen painful epididymis Urethritis
Epididymal tenderness or mass on exam
Symptoms:
Unilateral testicular pain and swelling
STD Atlas, 1997

51. Swollen or Tender Testicles (Epididymitis)
Source: Seattle STD/HIV Prevention Training Center at the University of Washington

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

53. 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

54. Gonococcal Ophthalmia in the Adult
Conjunctival erythema and discharge

55. Chemosis

56. 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

57. 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

58. 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

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

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

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

62. DGI Skin Lesion
Pustular erythematous lesions

63. DGI Skin Lesion
Papular erythematous skin lesion

64. 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

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

66. Gonorrhea Infection in Children
Perinatal: infections of the conjunctiva, pharynx, respiratory tract
Older children (>1 year): considered possible evidence of sexual abuse

67. 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

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

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

70. Lesson IV: Diagnosis

71. 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

72. Clinical Considerations
In cases of suspected sexual abuse
Legal standard is culture with multiple tests to confirm the identity of Neisseria gonorrhoeae

73. Gram Stain for GC: Urethral Smear
Numerous PMNs
Gram negative intracellular diplococci
PMN – Polymorphonuclear Antibodies
STD Atlas, 1997

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

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

76. GC Culture After 24 Hours
STD Atlas, 1997

77. Lesson V: Patient Management

78. 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

79. 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

80. 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

81. Lesson VI: Prevention

82. 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.

83. 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.

84. Reporting
Laws and regulations in all states require that persons diagnosed with gonorrhea are reported to public health authorities by clinicians, labs, or both.

85. 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

86. 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

87. 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

88. 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