Neisseria gonorrhoeae: Difference between revisions

Latest revision as of 14:34, 9 February 2022

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 Pc^R 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)

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.

@@ Line 1: / Line 1: @@
+==Background==
-* Causes '''gonorrhea'''
+*Causes '''gonorrhea'''
-== Epidemiology ==
+===Microbiology===
-* 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:CCDR2019]]
+*[[Stain::Gram-negative]] [[Shape::diplococcus]] within the genus [[Genus::Neisseria]]
-{{#scite:CCDR2019|type=journal|title=Multidrug-resistant and extensively drug-resistant gonorrhea in Canada, 2012–2016|journal=CCDR|year=2019|volume=45|issue=2/3|pages=45–53|doi=10.14745/ccdr.v45i23a01}}
+*Resistance
+**MDR gonorrhea: resistance to one of [[azithromycin]] or a [[cephalosporin]]
+**XDR if resistance to both [[azithromycin]] and a [[cephalosporin]]
+===Epidemiology===
-== Clinical Presentation ==
+*Resistance
-=== Anorectal gonorrhea ===
+**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===
-* Often asymptomatic
-* Can cause anorectal pain, discharge, and pruritis
-* Anal intercourse not required, especially in women
+*[[β-lactamases]], most commonly a TEM-1-type contained on a Pc<sup>R</sup> plasmid
-=== Disseminated gonococcal infection ===
+*Altered [[penicillin-binding protein]] PBP-2, encoded by ''penA''
+*Altered or downregulated porins, encoded by ''penB''
+*Increased efflux pump, encoded by ''mtr''
+==Clinical Manifestations==
-* Classically presents with tenosynovitis (often of wrists) or frank arthritis, with pustular lesions
-* Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis
-== Diagnosis ==
+=== Genital Infections ===
+* Causes [[cervicitis]] and [[urethritis]]
-* Resistance
+* In women, up to 70% are asymptomatic
-** MDR gonorrhea: resistance to one of azithromycin or a cephalosporin
+** In symptomatic women, the incubation period is about [[Usual incubation period::10 days]], followed by vaginal pruritis or mucopurulent discharge
-** XDR if resistance to both azithromycin and a cephalosporin
+** May have intermenstrual bleeding or menorrhagia
+* In men and women with [[urethritis]], it is usually asymptomatic
+** Incubation period is usually about [[Usual incubation period::3 to 5 days]], followed by urethral discharge and dysuria
+* [[Epididymitis]] in men is more commonly caused by [[Chlamydia trachomatis]]
+=== Pelvic Inflammatory Disease ===
-== References ==
+* See [[Pelvic inflammatory disease]], of which about 40% of cases are caused by ''Neisseria gonorrhoeae''
-<references/>
+* 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==
+*[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''}}