Neisseria gonorrhoeae: Difference between revisions
From IDWiki
Neisseria gonorrhoeae
(→) |
mNo edit summary |
||
| (7 intermediate revisions by the same user not shown) | |||
| Line 5: | Line 5: | ||
===Microbiology=== |
===Microbiology=== |
||
| − | *[[Stain::Gram-negative]] [[ |
+ | *[[Stain::Gram-negative]] [[Shape::diplococcus]] within the genus [[Genus::Neisseria]] |
*Resistance |
*Resistance |
||
**MDR gonorrhea: resistance to one of [[azithromycin]] or a [[cephalosporin]] |
**MDR gonorrhea: resistance to one of [[azithromycin]] or a [[cephalosporin]] |
||
| Line 16: | Line 16: | ||
**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 |
||
**XDR gonorrhea is still rare in Canada [[CiteRef::martin2019mu]] |
**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== |
==Clinical Manifestations== |
||
| + | === Genital Infections === |
||
| ⚫ | |||
| + | * Causes [[cervicitis]] and [[urethritis]] |
||
| + | * 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 |
||
| + | * [[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 |
||
| + | |||
| ⚫ | |||
*Often asymptomatic |
*Often asymptomatic |
||
*Can cause anorectal pain, discharge, and pruritis |
*Can cause anorectal pain, discharge, and pruritis |
||
*Anal intercourse not required, especially in women |
*Anal intercourse not required, especially in women |
||
| + | === Pharyngitis === |
||
| ⚫ | |||
| ⚫ | |||
| ⚫ | |||
| + | |||
| + | *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]] |
||
| ⚫ | |||
*Diagnosed with genital testing for gonorrhea, ± blood cultures or arthrocentesis |
*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== |
==Differential Diagnosis== |
||
| − | *Other causes of [[urethritis]] or [[septic arthritis]] |
+ | *Other causes of [[urethritis]] or [[septic arthritis]] or [[proctitis]] |
==Management== |
==Management== |
||
| Line 39: | Line 80: | ||
**First-line: [[ceftriaxone]] 250 mg IM once plus [[azithromycin]] 1 g PO once |
**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: [[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 |
+ | **Second-line: [[ciprofloxacin]] 500 mg PO once plus [[azithromycin]] 2 g PO once |
*Disseminated gonococcal infection |
*Disseminated gonococcal infection |
||
**Arthritis: [[ceftriaxone]] 2 g IV q24h for 7 days, plus [[azithromycin]] 1 g PO once |
**Arthritis: [[ceftriaxone]] 2 g IV q24h for 7 days, plus [[azithromycin]] 1 g PO once |
||
Latest revision as of 10:34, 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.
