View source for Neisseria gonorrhoeae

==Background==

*Causes '''gonorrhea'''

===Microbiology===

*[[Stain::Gram-negative]] [[Cellular shape::diplococcus]]
*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 [[CiteRef::martin2019mu]]

===Mechanisms of Resistance===

*[[β-lactamases]], most commonly a TEM-1-type contained on a Pc<sup>R</sup> 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==

===Anorectal gonorrhea===

*Often asymptomatic
*Can cause anorectal pain, discharge, and pruritis
*Anal intercourse not required, especially in women

===Disseminated gonococcal infection===

*Classically presents with tenosynovitis (often of wrists) or frank arthritis, with pustular lesions
*Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis

==Differential Diagnosis==

*Other causes of [[urethritis]] or [[septic arthritis]]

==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==

*[https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections.html#toc Canadian Guidelines on Sexually Transmitted Infections]

{{DISPLAYTITLE:''Neisseria gonorrhoeae''}}
[[Category:Gram-negative cocci]]
[[Category:Sexually-transmitted infections]]