Neisseria gonorrhoeae: Difference between revisions
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Neisseria gonorrhoeae
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==Background== |
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*Causes '''gonorrhea''' |
*Causes '''gonorrhea''' |
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===Microbiology=== |
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*[[Stain::Gram-negative]] [[Shape::diplococcus]] within the genus [[Genus::Neisseria]] |
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===Epidemiology=== |
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*Resistance |
*Resistance |
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**Rates of MDR gonorrhea is increasing in Canada, mostly driven by [[azithromycin]] resistance |
**Rates of MDR gonorrhea is increasing in Canada, mostly driven by [[azithromycin]] resistance |
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**XDR gonorrhea is still rare in Canada [[CiteRef::martin2019mu]] |
**XDR gonorrhea is still rare in Canada [[CiteRef::martin2019mu]] |
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===Mechanisms of Resistance=== |
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*[[β-lactamases]], most commonly a TEM-1-type contained on a Pc<sup>R</sup> plasmid |
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*Altered [[penicillin-binding protein]] PBP-2, encoded by ''penA'' |
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*Altered or downregulated porins, encoded by ''penB'' |
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*Increased efflux pump, encoded by ''mtr'' |
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==Clinical Manifestations== |
==Clinical Manifestations== |
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=== Genital Infections === |
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* Causes [[cervicitis]] and [[urethritis]] |
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* In women, up to 70% are asymptomatic |
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** In symptomatic women, the incubation period is about [[Usual incubation period::10 days]], followed by vaginal pruritis or mucopurulent discharge |
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** May have intermenstrual bleeding or menorrhagia |
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* In men and women with [[urethritis]], it is usually asymptomatic |
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** Incubation period is usually about [[Usual incubation period::3 to 5 days]], followed by urethral discharge and dysuria |
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* [[Epididymitis]] in men is more commonly caused by [[Chlamydia trachomatis]] |
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=== Pelvic Inflammatory Disease === |
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* See [[Pelvic inflammatory disease]], of which about 40% of cases are caused by ''Neisseria gonorrhoeae'' |
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* Pelvic and abdominal pain, vaginal bleeding, and [[dyspareunia]] |
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* May be febrile and acutely unwell |
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=== Fitz-Hugh-Curtis Syndrome === |
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* Aka perihepatitis, with inflammation of Glisson's capsule around the liver |
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* More often associated with [[Chlamydia trachomatis]] |
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=== Bartholinitis === |
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* Inflammation of Bartholin's glands, which are behind the labia |
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* Labial pain, swelling, tenderness, and discharge |
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*Often asymptomatic |
*Often asymptomatic |
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*Can cause anorectal pain, discharge, and pruritis |
*Can cause anorectal pain, discharge, and pruritis |
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*Anal intercourse not required, especially in women |
*Anal intercourse not required, especially in women |
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=== Pharyngitis === |
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===Disseminated Gonococcal Infection=== |
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*Occurs in about 1% of patients with gonorrhea, and most strains do not cause urethritis |
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**Risk factors include female sex, menstruation, pregnancy, and [[terminal complement deficiency]] |
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*Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis |
*Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis |
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*Other (rare) sites of dissemination include [[endocarditis]], [[meningitis]], and [[osteomyelitis]] |
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=== Conjunctivitis === |
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== Differential Diagnosis == |
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* Occurs in infants born to untreated, infected mothers, and rarely from spread by fomites or flies |
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==Diagnosis== |
==Differential Diagnosis== |
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==Management== |
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*Anogenital and pharyngeal infection in people ≥9 years of age |
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*Repeat screening at 6 months |
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===Test of Cure=== |
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*Done at 3 to 7 days if by culture or 14 to 21 days if NAAT |
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* Urethritis |
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*Indications include: |
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**Pharyngeal infection |
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**Persistent signs or symptoms |
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**Treated without ceftriaxone |
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**Treated with fluoroquinolone, without susceptibility testing |
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**Epidemiologic link to a resistant case |
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**Documented microbiologic resistance |
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**Epidemiologic link to treatment failure |
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**Previous treatment failure |
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**Uncertain adherence to treatment |
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**Reexposure to untreated partener |
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**Pregnancy |
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**Pediatric patient |
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**[[Pelvic inflammatory disease]] with documented gonorrhea |
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**Therapeutic abortion (increased risk of developing PID) |
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==Further Reading== |
==Further Reading== |
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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 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.
