Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
This article have been viewed 1433 times
Jacqueline A. Guidry and Ted Rosen
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Gonorrhea is a common and potentially severe sexually transmitted disease caused by the Gram-negative aerobic diplococcus Neisseria gonorrhoeae. This organism primarily infects the mucous membranes of the urethra, endocervix, rectum, and pharynx. The disease can also become disseminated, causing petechial or acral pustular skin lesions, tenosynovitis, arthralgia, true septic arthritis, perihepatitis, and less commonly endocarditis or meningitis. Dissemination is more common in women. Conversely, the infection may be asymptomatic.
Individuals with gonorrhea should be treated as promptly as possible: (a) to prevent regional infection such as epididymitis or pelvic inflammatory disease leading to infertility or ectopic pregnancy; (b) to prevent disseminated gonococcal infection, which occurs in about 1–3% of cases; and (c) to stop transmission to sexual partners. Prompt management has become especially important due to resurgence in incidence of gonococcal disease in the US and increasing antimicrobial resistance worldwide.
Gonococcal urethritis is typically characterized by mucopurulent to frankly purulent discharge along with a burning sensation during urination. In the absence of discharge, dysuria may be the only symptom.
Gonococcal cervicitis is characterized by a mucopurulent or purulent endocervical exudate. However, a cervical discharge is not specific for a gonococcal infection, and gonococcal infection of the cervix is often asymptomatic.
Pharyngeal infection is asymptomatic in more than 90% of cases.
Rectal infection is prevalent in homosexual men, causing anal discharge and pain. In women, rectal infection results from spread through vaginal secretions and does not necessarily imply anal intercourse.
Patients in whom gonorrhea is suspected should be investigated using the most sensitive and specific tests, though empiric treatment of the symptoms may be recommended for patients at high risk for infection who are deemed unlikely to return for a follow-up evaluation.
Patients infected with N. gonorrhoeae are often co-infected with Chlamydia trachomatis and should be treated with azithromycin or doxycycline to cover this organism, with or without diagnostic evidence of chlamydial disease. Patients with gonorrhea should be tested for both syphilis and HIV.
Patients should be instructed to return for evaluation if symptoms persist or recur after therapy, and to abstain from sexual intercourse until they and their sexual partners are cured. Because re-infection is so common, the CDC recommends that all patients with known gonorrhea return for re-testing 3 months post-treatment. A test-of-cure 3 to 4 weeks post-treatment is no longer recommended.
Antimicrobial resistance is a real threat and treatment options for gonococcal disease are increasingly limited. To abate further spread of resistant strains of N. gonorrhoeae, physicians should strongly encourage patient referral of any sexual partner within the preceding 60 days for evaluation and treatment, and obtain culture(s) to evaluate individual antimicrobial susceptibility in any patient whose symptoms do not resolve with initial treatment.
Men
Microscopic examination of Gram-stained urethral secretions
Culture on Thayer–Martin medium
Non-culture test based upon immunodiagnostics, as available
Women
Janier M, Lassau F, Casin I, Grillot P, Scieux C, Zavaro A, et al. Sex Transm Dis 1995; 22: 244–52.
N. gonorrhoeae was found in 21% of patients with urethral discharge and in no patient without discharge. Treatment for N. gonorrhoeae in patients without discharge in the absence of proven contact with an infected patient is not recommended.
Workowski KA, Berman S. MMWR Recomm Rep 2010; 59(RR12): 49–55.
Because of its high specificity (>99%) and sensitivity (>95%), a Gram stain of a male urethral specimen that demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci can be considered diagnostic for infection with N. gonorrhoeae in symptomatic men. Culture is the most widely available option for diagnosis in asymptomatic men, in women, and in non-genital sites (rectum and pharynx). Non-culture tests cannot provide antimicrobial susceptibility results but can rapidly and accurately confirm a clinical diagnosis.
MMWR 2002; 51(RR-15): 1–48.
Non-culture tests called nucleic acid hybridization tests and nucleic acid amplification tests (NAATs) have been developed. Commercial NAATs differ in their amplification methods and their target nucleic acid sequences. The majority of commercial NAATs have been cleared by the FDA to detect C. trachomatis and N. gonorrhoeae in endocervical swabs and urethral swabs from men. The sensitivity of NAATs might be less when using urine than when using an endocervical swab. Testing of rectal and oropharyngeal specimens with NAATs is not recommended.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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