Neisseria gonorrhoeae
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Neisseria gonorrhoeae / (Redirected from Disseminated gonococcal infection)
Background
- Causes gonorrhea
Microbiology
- Gram-negative diplococcus within the genus Neisseria
- Resistance
- MDR gonorrhea: resistance to one of azithromycin or a cephalosporin
- XDR if resistance to both azithromycin and a cephalosporin
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
- Risk factors include female sex, menstruation, pregnancy, and terminal complement deficiency
- 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
- Other causes of urethritis or septic arthritis or proctitis
Management
- Anogenital and pharyngeal infection in people ≥9 years of age
- First-line: ceftriaxone 250 mg IM once plus azithromycin 1 g PO once
- Second-line: gentamicin 240 mg IM once (in 2 doses) plus azithromycin 2 g PO once
- Second-line: ciprofloxacin 500 mg PO once plus azithromycin 2 g PO once
- Disseminated gonococcal infection
- Arthritis: ceftriaxone 2 g IV q24h for 7 days, plus azithromycin 1 g PO once
- Meningitis: ceftriaxone 2 g IV q24h for 10-14 days, plus azithromycin 1 g PO once
- Endocarditis: ceftriaxone 2 g IV q24h for 28 days, plus azithromycin 1 g PO once
- Ophthalmia: ceftriaxone 2 g IV once, plus azithromycin 1 g PO once
- 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
References
- ^ I Martin, P Sawatzky, V Allen, B Lefebvre, LMN Hoang, P Naidu, J Minion, P Van Caeseele, D Haldane, RR Gad, G Zahariadis, A Corriveau, G German, K Tomas, MR Mulvey. Multidrug-resistant and extensively drug-resistant Neisseria gonorrhoeae in Canada, 2012–2016. Canada Communicable Disease Report. 2019;45(2/3):45-53. doi:10.14745/ccdr.v45i23a01.