Sexually Transmitted Infections: Gonorrhea

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Chapter 48 Sexually Transmitted Infections: Gonorrhea

INTRODUCTION

Description: Infection with gonorrhea, a gram-negative intracellular diplococcus, remains common, accounting for 358,366 new cases of gonorrhea in the United States in 2006.
Prevalence: Roughly 3 of 1000 sexually active women and as many as 7% of pregnant patients; 120.9 per 100,000 women.
Predominant Age: 15 to 30 (85%), highest age 15 to 19 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection by the gram-negative intracellular diplococcus, Neisseria gonorrhoeae.
Risk Factors: It is estimated that the rate of infection with one act of intercourse with an infected partner is 20% for men but 60% to 80% for women. (For this reason, any patient exposed to gonorrhea within the preceding month should be cultured and treated presumptively.) This rate increases to 60% to 80% for both sexes with four or more exposures. The groups with the highest risk are adolescents, drug users, and sex workers.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic (50%)
• Malodorous, purulent discharge from the urethra, Skene duct, cervix, vagina, or anus (even without rectal intercourse) 3 to 5 days after exposure (40% to 60%)
• Simultaneous urethral infection (70% to 90%)
• Infection of the pharynx (10% to 20%)
• Gonococcal conjunctivitis (can rapidly lead to blindness)
• Polyarthritis
• Septic abortion or postabortal sepsis

DIAGNOSTIC APPROACH

Differential Diagnosis

• Chlamydial infection
• Pelvic inflammatory disease (PID)
• Septic abortion
• Appendicitis
• Gastroenteritis

Associated Conditions: Infertility, ectopic pregnancy, mucopurulent cervicitis, pelvic inflammatory disease (10% to 40% of untreated cases), chronic pelvic pain, and endometritis.

Workup and Evaluation

Laboratory: Culture on Thayer-Martin agar plates kept in a CO2-rich environment. Cervical cultures provide 80% to 95% diagnostic sensitivity. Cultures should also be obtained from the urethra and anus, although these additional cultures do not significantly increase the sensitivity of testing. A Gram stain of any cervical discharge for the presence of gram-negative intracellular diplococcus supports the presumptive diagnosis but does not establish it (sensitivity 50% to 70%, specificity 97%). A solid-phase enzyme immunoassay may also be used. Even when the diagnosis is established by other methods, all cases of gonorrhea should have cultures obtained to assess antibiotic susceptibility, although therapy should not be delayed pending the results.
Imaging: No imaging indicated. Ultrasonography may demonstrate free fluid in the cul-de-sac when pelvic inflammation is present.
Special Tests: None indicated.
Diagnostic Procedures: Physical examination, suspicion, and cervical culture.

Pathologic Findings

Gram-negative intracellular diplococcus associated with diffuse inflammatory reaction (transluminal in the fallopian tube).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation and diagnosis.
Specific Measures: Aggressive antibiotic therapy should be instituted in patients suspected of having an infection.
Diet: No specific dietary changes indicated.
Activity: No restriction. (Sexual continence is required until the infection has resolved.)
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Drug(s) of Choice

Ceftriaxone 125 mg IM or cefixime 400 mg PO single dose or
Ciprofloxacin 500 mg PO single dose or
Ofloxacin 400 mg orally in a single dose* or
Levofloxacin250 mg orally in a single dose*
Contraindications: Quinolones (Ofloxacin), tetracyc-lines (including doxycycline), and erythromycin estolate are contraindicated in pregnancy and should not be used.
Precautions: See individual agents.
Interactions: See individual agents.

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Alternative Drugs

Spectinomycin 2 g IM as single dose.
Ceftriaxone 125 mg IM and cefixime 400 mg PO as single dose.
Ceftizoxime 500 mg IM, cefotaxime 500 mg IM, or cefotetan 1 g IM, all as single dose.
Cefoxitin 2 g IM plus probenecid 1 g PO.
Cefuroxime axetil 1 g PO or cefpodoxime proxetil 200 mg PO, both as single dose.
Enoxacin 400 mg PO, lomefloxacin 400 mg PO, or norfloxacin 800 mg PO, all as single dose.

FOLLOW-UP

Patient Monitoring: When patients are treated with the currently recommended ceftriaxone–doxycycline, therapy failure is rare and a follow-up culture is not necessary. Reexamination of the patient in 1 to 2 months for the possibility of reinfection may be warranted in patients at high risk. (As with all sexually transmitted diseases, all sexual partners within the preceding 30 days should be screened and treated for probable infections.)
Prevention/Avoidance: Use of barrier contraception (condoms, diaphragm), limitation or elimination of risky behavior (sexual promiscuity).
Possible Complications: Damage caused by N. gonorrhoeae infection causes an increased risk of recurrent pelvic infection, chronic pelvic pain, or infertility resulting from tubal damage or hydrosalpinx formation. The impact of a gonorrheal infection is much greater for women than it is for men. For every three men infected, two women are hospitalized for 1 or more days. For every 18 men infected, 1 woman undergoes surgery. It is estimated that one episode of gonorrhea is associated with a 15% infertility rate; this increases to 75% for three or more infections. The risk of an ectopic pregnancy is increased 7 to 10 times in women with a history of salpingitis. Neonatal infections acquired from a mother with gonorrhea may result in conjunctivitis or pneumonia. Pregnant patients are more likely to experience disseminated gonococcal infection. They account for 7% to 40% of all cases.
Expected Outcome: If detected early, successful treatment with minimal sequelae may be expected. Significant permanent damage is common despite treatment because of the indolent course of many infections and the late institution of therapy.

MISCELLANEOUS

Pregnancy Considerations: Pregnant patients should be treated with ceftriaxone 250 mg IM as a single dose. Erythromycin (erythromycin base, 500 mg PO four times a day for 7 days) may be added if there is a possibility of a coexisting chlamydial infection. Neonatal conjunctivitis and ophthalmia neonatorum may result if the infant does not receive adequate prophylaxis.
ICD-9-CM Codes: 098.0 (Acute, lower genital tract), 098.1 (Acute, upper genital tract) (others based on chronicity and organ involved).

REFERENCES

Level II

Centers for Disease Control and Surveillance. Decreased susceptibility of Neisseria gonorrhoeae to fluoroquinolones—Ohio and Hawaii, 1992–1994. MMWR. 1994;43:325.

Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005;352:676.

Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003;139:178.

Phillips RS, Hanff PA, Wertheimer A, Aronson MD. Gonorrhea in women seen for routine gynecologic care: criteria for testing. Am J Med. 1988;85:177.

Ramus R, Mayfield J, Wendel G. Evaluation of the current CDC recommended treatment guidelines for gonorrhea in pregnancy. Am J Obstet Gynecol. 1996;174:409.

Level III

Centers for Disease Control and Prevention. Sexually transmitted disease surveillance, 2004. Atlanta, GA: U.S. Department of Health and Human Services, CDC, National Center for HIV, STD, and TB Prevention, 2005.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:21. 38.

Centers for Disease Control and Prevention. Updated recommended treatment regimens for gonococcal infections and associated conditions—United States, April 2007. MMWR. 2007;56:332.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:599.

* Quinolones should not be used for infections in men who have sex with men or in patients with a history of recent foreign travel or partners’ travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased quinolone-resistant N. gonorrhoeae (QRNG) prevalence.

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