Neisseria gonorrhoeae: Difference between revisions

Revision as of 18:35, 28 August 2020

Background

Causes gonorrhea

Microbiology

Gram-negative 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 1

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

Urethritis
- 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'''
+=== Microbiology ===
-==Epidemiology==
+* [[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
@@ Line 21: / Line 30: @@
 *Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis
-== Differential Diagnosis ==
+==Differential Diagnosis==
-* Other causes of [[urethritis]] or [[septic arthritis]]
+*Other causes of [[urethritis]] or [[septic arthritis]]
-==Diagnosis==
+==Management==
+*Urethritis
-*Resistance
-**MDR gonorrhea: resistance to one of azithromycin or a cephalosporin
+**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
-**XDR if resistance to both azithromycin and a cephalosporin
+**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
-== Management ==
+=== Test of Cure ===
+* Done at 3 to 7 days if by culture or 14 to 21 days if NAAT
-* Urethritis
+* Indications include:
-** First-line: [[ceftriaxone]] 250 mg IM once plus [[azithromycin]] 1 g PO once
+** Pharyngeal infection
-** Second-line: [[gentamicin]] 240 mg IM once (in 2 doses) plus [[azithromycin]] 2 g PO once
+** Persistent signs or symptoms
-** Second-line: [[ciprofloxacin]] 500 mg PO once plus azithromycin 2 g PO once
+** Treated without ceftriaxone
-* Disseminated gonococcal infection
+** Treated with fluoroquinolone, without susceptibility testing
-** Arthritis: [[ceftriaxone]] 2 g IV q24h for 7 days, plus [[azithromycin]] 1 g PO once
+** Epidemiologic link to a resistant case
-** Meningitis: [[ceftriaxone]] 2 g IV q24h for 10-14 days, plus [[azithromycin]] 1 g PO once
+** Documented microbiologic resistance
-** Endocarditis: [[ceftriaxone]] 2 g IV q24h for 28 days, plus [[azithromycin]] 1 g PO once
+** Epidemiologic link to treatment failure
-** Ophthalmia: [[ceftriaxone]] 2 g IV once, plus [[azithromycin]] 1 g PO once
+** 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==