Neisseria gonorrhoeae: Difference between revisions

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Neisseria gonorrhoeae
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==Background==
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* Causes '''gonorrhea'''
  
   
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*Causes '''gonorrhea'''
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== Epidemiology ==
  
   
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===Microbiology===
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* 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 <ref>[[CiteRef::martin2019mu]]</ref>
  
   
  +
*[[Stain::Gram-negative]] [[Shape::diplococcus]] within the genus [[Genus::Neisseria]]
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== Clinical Presentation ==
  
  +
*Resistance
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**MDR gonorrhea: resistance to one of [[azithromycin]] or a [[cephalosporin]]
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**XDR if resistance to both [[azithromycin]] and a [[cephalosporin]]
   
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=== Anorectal gonorrhea ===
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===Epidemiology===
   
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*Resistance
−
* Often asymptomatic
  
  +
**About 50% resistance to [[fluoroquinolones]]
−
* Can cause anorectal pain, discharge, and pruritis
  
  +
**Rates of MDR gonorrhea is increasing in Canada, mostly driven by [[azithromycin]] resistance
−
* Anal intercourse not required, especially in women
  
  +
**XDR gonorrhea is still rare in Canada [[CiteRef::martin2019mu]]
   
  +
===Mechanisms of Resistance===
−
=== Disseminated gonococcal infection ===
  
   
  +
*[[β-lactamases]], most commonly a TEM-1-type contained on a Pc<sup>R</sup> plasmid
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* Classically presents with tenosynovitis (often of wrists) or frank arthritis, with pustular lesions
  
  +
*Altered [[penicillin-binding protein]] PBP-2, encoded by ''penA''
−
* Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis
  
  +
*Altered or downregulated porins, encoded by ''penB''
  +
*Increased efflux pump, encoded by ''mtr''
   
  +
==Clinical Manifestations==
−
== Diagnosis ==
  
   
  +
=== Genital Infections ===
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* Resistance
  
−
** MDR gonorrhea: resistance to one of azithromycin or a cephalosporin
  
−
** XDR if resistance to both azithromycin and a cephalosporin
  
   
  +
* Causes [[cervicitis]] and [[urethritis]]
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== References ==
  
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* In women, up to 70% are asymptomatic
  +
** In symptomatic women, the incubation period is about [[Usual incubation period::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 [[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]]
   
  +
=== Pelvic Inflammatory Disease ===
−
<references/>
  
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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]]
  +
* May be febrile and acutely unwell
  +
  +
=== 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]]
  +
  +
=== Bartholinitis ===
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  +
* 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
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**Risk factors include female sex, menstruation, pregnancy, and [[terminal complement deficiency]]
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*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]]
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  +
==Management==
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  +
*Anogenital and pharyngeal infection in people ≥9 years of age
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**First-line: [[ceftriaxone]] 250 mg IM once plus [[azithromycin]] 1 g PO once
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**Second-line: [[gentamicin]] 240 mg IM once (in 2 doses) plus [[azithromycin]] 2 g PO once
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**Second-line: [[ciprofloxacin]] 500 mg PO once plus [[azithromycin]] 2 g PO once
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*Disseminated gonococcal infection
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**Arthritis: [[ceftriaxone]] 2 g IV q24h for 7 days, plus [[azithromycin]] 1 g PO once
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**Meningitis: [[ceftriaxone]] 2 g IV q24h for 10-14 days, plus [[azithromycin]] 1 g PO once
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**Endocarditis: [[ceftriaxone]] 2 g IV q24h for 28 days, plus [[azithromycin]] 1 g PO once
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**Ophthalmia: [[ceftriaxone]] 2 g IV once, plus [[azithromycin]] 1 g PO once
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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
  +
*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==
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  +
*[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''}}
  
{{DISPLAYTITLE:''Neisseria gonorrhoeae''}}

Latest revision as of 10:34, 9 February 2022

Background

  • Causes gonorrhea

Microbiology

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
  • 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

Management

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

  1. ^  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.

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