Background
Microbiology
Gram-negative diplococcus within the genus Neisseria
Resistance
Epidemiology
Resistance
About 50% resistance to fluoroquinolones
Rates of MDR gonorrhea is increasing in Canada, mostly driven by azithromycin resistance
XDR gonorrhea is still rare in Canada 1
Mechanisms of Resistance
β-lactamases , most commonly a TEM-1-type contained on a PcR plasmid
Altered penicillin-binding protein PBP-2, encoded by penA
Altered or downregulated porins, encoded by penB
Increased efflux pump, encoded by mtr
Clinical Manifestations
Genital Infections
Causes cervicitis and urethritis
In women, up to 70% are asymptomatic
In symptomatic women, the incubation period is about 10 days, followed by vaginal pruritis or mucopurulent discharge
May have intermenstrual bleeding or menorrhagia
In men and women with urethritis , it is usually asymptomatic
Incubation period is usually about 3 to 5 days, followed by urethral discharge and dysuria
Epididymitis in men is more commonly caused by Chlamydia trachomatis
Pelvic Inflammatory Disease
See Pelvic inflammatory disease , of which about 40% of cases are caused by Neisseria gonorrhoeae
Pelvic and abdominal pain, vaginal bleeding, and dyspareunia
May be febrile and acutely unwell
Fitz-Hugh-Curtis Syndrome
Aka perihepatitis, with inflammation of Glisson's capsule around the liver
More often associated with Chlamydia trachomatis
Bartholinitis
Inflammation of Bartholin's glands, which are behind the labia
Labial pain, swelling, tenderness, and discharge
Anorectal Gonorrhea
Often asymptomatic
Can cause anorectal pain, discharge, and pruritis
Anal intercourse not required, especially in women
Pharyngitis
Disseminated Gonococcal Infection
Occurs in about 1% of patients with gonorrhea, and most strains do not cause urethritis
Classically presents with either septic arthritis, or with a triad of tenosynovitis (often of wrists) dermatitis (with pustular lesions), and arthritis
Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis
Other (rare) sites of dissemination include endocarditis , meningitis , and osteomyelitis
Conjunctivitis
Occurs in infants born to untreated, infected mothers, and rarely from spread by fomites or flies
Differential Diagnosis
Management
Anogenital and pharyngeal infection in people ≥9 years of age
Disseminated gonococcal infection
Repeat screening at 6 months
Test of Cure
Done at 3 to 7 days if by culture or 14 to 21 days if NAAT
Indications include:
Pharyngeal infection
Persistent signs or symptoms
Treated without ceftriaxone
Treated with fluoroquinolone, without susceptibility testing
Epidemiologic link to a resistant case
Documented microbiologic resistance
Epidemiologic link to treatment failure
Previous treatment failure
Uncertain adherence to treatment
Reexposure to untreated partener
Pregnancy
Disseminated gonococcal infection
Pediatric patient
Pelvic inflammatory disease with documented gonorrhea
Therapeutic abortion (increased risk of developing PID)
Further Reading