Published on February 19, 2014
BY DR. BHAGWAN DASS
Gonorrhea (Greek, “flow of seed”) is attributed to Galen (130 A.D.), who is said to have believed that urethral exudate in males with gonorrhea was semen. In 1879, Neisseria gonorrhoeae was demonstrated by Neisser in stained smears of urethral, vaginal, and conjunctival exudates, making gonococcus 2nd identified bacterial pathogen following discovery of Bacillus anthracis. First cultured in vitro by Leistikow in 1882 Effective antimicrobial therapy in form of sulfonamides was first applied in 1930s.
Thayer- Martin medium for culture:- 1962 Risk of infection for a man after single episode of vaginal intercourse with an infected woman is estimated to be 20% and 60-80% after 4 exposure. Prevalence of infection in women is 50-90%. N. Gonorrhoeae is gram –ve, nonmotile, non-spore forming diplococci. Present intracellularly in neutrophils.
Only mucous membranes lined by columnar or cuboidal, 1. 2. noncornified epithelial cells are susceptible to gonococcal infection. Steps in pathogenesis:Adherence :- initial event , N. gonorrhoeae adhere to mucosal cells , mediated by pili, Opa, and other surface proteins. Invasion :-Organism is then pinocytosed by epithelial cells, which transport gonococci from mucosal surface to subepithelial spaces. Simultaneous with attachment of gonococci to nonciliated epithelial cells, gonococcal LOS(endotoxin) impairs ciliary motility and contributes to destruction of surrounding ciliary cells.
This process may promote further attachment of additional organisms. 3. Tissue damage :-Progressive mucosal cell damage and submucosal invasion are accompanied by a vigorous neutrophil response, submucosal microabscess formation, and exudation of purulent material into lumen of the infected organ. 4. Dissemination:- ability to resist the killing activity of antibodies and complement in normal human serum is closely related to the ability of gonococci to cause bacteremic illness with or without septic arthritis
URETHRAL INFECTION IN MEN Acute anterior urethritis is most common in men. incubation period ranges from 1 to 14 days or even longer; however, majority of men develop symptoms within 2–5 days, as was the case in 36 (82%) of 44 men with uncomplicated gonorrhea in one of few studies in which time of exposure could be clearly defined. Predominant symptoms are urethral discharge or dysuria initially scant and mucoid or mucopurulent in appearance, in most males urethral exudate becomes frankly purulent and relatively profuse within 24 hours of onset. Dysuria usually begins after onset of discharge.
Variable degrees of edema and erythema of the urethral meatus commonly accompany gonococcal urethritis.
UROGENITAL INFECTION IN WOMEN Primary site:- endocervical canal Urethral colonization :70–90% of infected women, but is uncommon in absence of endocervical infection. Infection of Bartholin’s gland ducts is also common. IP:- variable but usually 10 days
Most common symptoms are those of most lower genital tract infections in women: increased vaginal discharge, dysuria, intermenstrual uterine bleeding, and menorrhagia. Purulent exudate occasionally may be expressed from urethra or Bartholin’s gland duct.
RECTAL INFECTION Rectal mucosa is infected in 35–50% of women with gonococcal cervicitis. Only rectum is involved in 5% women. 40% in homosexual men. Symptoms range from minimal anal pruritus, painless mucopurulent discharge (often manifested only by a coating of stools with exudate), or scant rectal bleeding, to symptoms of overt proctitis, including severe rectal pain, tenesmus, and constipation.
External inspection :- only occasionally shows erythema and abnormal discharge On Anoscopy:- mucoid or purulent exudate ( localized to anal crypts), erythema, edema, friability, or other inflammatory mucosal changes.
PHARYNGEAL INFECTION 3–7% of heterosexual men, 10–20% of heterosexual women, and 10–25% of homosexually active men. acute pharyngitis or tonsillitis and occasionally is associated with fever or cervical lymphadenopathy. >90% are asymptomatic
INFECTION OF OTHER SITES Gonococcal conjunctivitis is rare. Primary cutaneous infection i.e. localized ulcer of genitals, perineum, proximal lower extremities, or finger is rare.
COMPLICATED GONOCOCCAL INFECTIONS LOCAL COMPLICATIONS IN MEN: Epididymitis:-present in upto 20%. most common causes of acute epididymitis in patients under age 35 are C. trachomatis, N. gonorrhoeae Penile lymphangitis:- penile edema (“bull-headed clap”) Post-inflammatory urethral strictures Periurethral abscesses LOCAL COMPLICATIONS IN WOMEN: PID:- most common of all complications of gonorrhea, as well as the most important in terms of public-health impact 10–20% of those with acute gonococcal infection.
Bartholin’s gland abscess SYSTEMIC COMPLICATIONS: DISSEMINATED GONOCOCCAL INFECTION:- More common in female. DGI, usually manifested by acute arthritis-dermatitis syndrome, is most common systemic complication of acute gonorrhea. “classic” skin lesion of gonococcal dermatitis:- a tender, necrotic pustule on an erythematous base, may present as, macules, papules, pustules, petechiae, bullae, or ecchymoses
Located on distal portions of extremities and <30. Gonococcal endocarditis and meningitis:- Occurs in 1–3% of patients with DGI.
LABORATORY DIAGNOSIS Gram’s stain:- Microscopic examination of stained smears shows gram –ve diplococci in PMN are seen. Culture:- antibiotic-containing selective media (e.g., modified Thayer- Martin medium) have diagnostic sensitivities of 80– 95% for promptly incubated specimens, depending in part on anatomic site being cultured. Small pinpoint colonies can be seen. 90% within 12 hrs and 100% within 6 hrs of sample collection
Oxidase reaction:- aids to identify gonococci from mixed culture A drop of tetra methyl-p-phenylene diamine hydrochloride is poured over suspected colonies, which turn pink and then dark blue Nonculture diagnostic techniques:Nucleic acid amplification tests (NAATs):- polymerase chain reaction (PCR), transcription-mediated amplification (TMA), and other nucleic acid amplification technologies. More sensitive than culture for gonorrhea diagnosis and specificities are nearly as high as for culture.
Immunologic or biochemical detection of gonococcal antigens or metabolic products, including surface proteins, endotoxin and oxidase or other enzymes also has been investigated in past but currently seem less promising than nucleic acid detection. Fluorescein-conjugated antibodies detection give positive results 24 hours before conventional culture technique.
SEROLOGICAL DIAGNOSIS complement fixation, immunoprecipitation, bacterial lysis, immunofluorescence, hemagglutination, latex agglutination, enzyme-linked immunoabsorbance, and other techniques. sensitivities of about 70% and specificities of about 80%. Rapid carbohydrate utilization test(RCUT):-used to detect β lactamase production by Neisseria species. Detected by change in colour of phenol red pH indicator from red to yellow.
Treatment Uncomplicated Gonococcal infection of cervix, urethra and rectum Single dose of Tab. cefixime 400mg, Inj. Ceftriaxone 125 mg IM, tab. Ciprofloxacin 500mg, tab. Ofloxacin 400mg, or tab. Levofloxacin 250mg PLUS If chlamydial infection is not ruled out- tab. Azithromycin 1 g single dose or tab. Doxycyclin 100mg BID x 7days. Uncomplicated Gonococcal infection of pharynx Single dose of Inj. Ceftriaxone 125 mg IM, or tab. Ciprofloxacin 500mg PLUS If chlamydial infection is not ruled out- tab. Azithromycin 1 g single dose or tab. Doxycyclin 100mg BID x 7days
Disseminated gonococcal infection (DGI)_ Inj. Ceftriaxone 1 g IM or IV daily Alternative regimens Inj. Cefotaxime 1 g IV 8 hourly, Inj. Ceftizoxime 1 g IV 8 hourly, Inj. Ciprofloxacin 400 mg IV BD, Inj. Ofloxacin 400mg IV BD, Inj. Levofloxacin 250mg IV daily OR Inj. Spectinomycin 2 g IM BD All of the preceding regimens should be continued for 24-48 hrs after improvement begins, at which time therapy may be switched to one of the following regimens to complete at least 1 week of therapy Tab. Cefixime 400mg BD, tab. Ciprofloxacin 500mg BD, ofloxacin 400mg BD OR tab. Levofloxacin 500mg OD Gonococcal conjuctivitis:Inj. Ceftriaxone 1 g IM single dose Gonococcal meningitis:- Inj. Ceftriaxone 1-2 g IV every 12 hrs x 10-14 days. Gonococcal endocarditis:- Inj. Ceftriaxone 1-2 g IV every 12 hrs for at least 4 weeks Ophthalmia neonatorum:Inj. Ceftriaxone 25-50 mg/kg IV/IM single dose( not more than 125 mg)
Management of Sex partners:- all sex partners of patient who have N. gonorroeae infection should be evaluate and treated for both N. gonorroeae and C. trachomatis if their last sexual contact with patient was within 60 days before onset of symptoms or diagnosis. Follow up:- Treated patients with CDC regimen need not follow up to confirm their cure but the patient with persistent symptoms may be tested for antimicrobial susceptibility and other cause and tested accordingly.
Flowchart for management of urethral discharge(NACO 2007) Syndrome:- urethral discharge in man History of:-Urethral discharge •Pain or burning while passing urine, increased frequency of urination •Sxual exposure to high risk practices including oro-genital sex Examination:•Look for urethral meatus for redness and swelling •If urethral discharge is not seen, then gently masage the urethra from ventral part of penis towards meatus and thick, creamy greenish-yellow or mucoid discharge Lab investigations:•Gram stain examination of urethral smear will show G –ve intracellular diplococci in case of gonorrhoea •In non gonocacal urethritis more than 5 PMN cells per oil immersion field in urethral smear or >10 PMN cells/high power field in the sediment of first void urine are observed.
TREATMENT Dual infection is common, t/t should cover all the 3 organism Regimen for uncomplicated gonorrhoea + chlamydia •Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat, and advise client to return after 7 days. When the symptoms persist or recur in patient or partner then •Tab secnidazole 2 g stat SYNDROME SPECIFIC GUIDELINES FOR PARTNER MANAGEMENT •Treat all recent partners •Treat partners on same lines •Advise sexual absinence durind the course of treatment or provide condoms. •Refer for voluntary counselling and testing for HIV, syphilis and hepatitis B. •Advise to return after 7 days. FOLLOW UP AFTER 7 DAYS •See reports of HIV, syphilis and hepatitis B •If symptoms persist, to assess t/t failure or reinfection MANAGEMENT OF PREGNANT PARTNER •Tab. Cefixime 400 mg stat or Inj. Ceftriaxone 125 mg IM stat PLUS •Tab. Erythromycin 500 mg QID x 7 days or Cap. Amoxicillin 500 mg TDS x 7 days.
Management of vaginal discharge syndrome (NACO 2007) History :- menstrual history to rule out pregnancy •Nature and type of discharge(amount, smell, consistency) •Genital itching •Burning micturation, frequrncy of urination •Presence of any ulcer, swelling on the vulval or inguinal region •Genital complaints in sexual partners •Low backache EXAMINATION •Per speculum examination to differntiate b/w vaginitis and cervicitis. a) Vaginitis:• Trichomoniasis:- greenish frothy discharge • Candidiasis:- curdy white discharge • Bacterial vaginosis:- adherent discharge • Mixed infection may present with atypical discharge. b) Cervicitis:• Cervical erosion/ cervical ulcer/ mucopurulent cervical discharge. • Bimanual pelvic examination to rule out PID • If speculum examination is not possible or client is hesitant, treat both for vaginitis and cervicitis
Lab investigations •Wet mount microscopy of the discharge for trichomonas vaginalis and clue cells •10% KOH for candidiasis •Grams stain of vaginal smear for clue cells •Grams stain of endocervical smear to detect gonococci. TREATMENT •VAGINITIS (TV+BV+Candida):•Tab. Fluconazole 150 mg stat or Local clotrimazole 500 mg vaginal pessary once •Tab. Secnidazole 2 g stat or Tab. Tinidazole 500 mg BD x 5 days . •CERVICAL INFECTION( chlamydia and gonorrhoea ):•Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat Management of pregnant women •Vaginitis :•First trimester of pregnancy:- local t/t with clotrimazole vaginal pessary/cream •Local Metronitazole pessary/cream. •Second trimester of pregnancy:- Tab. Secnidazole 2 g stat or tab tinidazole 500 mg BD x5 days Partner treatment guideline •Treat partner only if no improvement after initial t/t or partner is symptomatic.
Epidemiologie. Bei der Gonorrhoe handelt es sich um eine weltweit vorkommende, ausschließlich beim Menschen auftretende sexuell übertragbare Erkrankung.
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