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Gelerstein 2011

Topic 27. Diagnosis and treatment of gonorrhoea Neisseria Gonorrhea Gonorrhea = abnormal flow of semen (Galen) gonos = seed, rhoea = flow Hunter: autoinoculation with gonococci urethral exudate Neisser: identification of the diplococcal 400,000 cases in the USA in 1995 resistance to antibiotics Etiologic Agent and Pathogenesis Bacterial infection Only natural reservoir is humans Almost exclusively by sexual intercourse Pathogen: Neisseria gonorrhea (gram (-) diplococci) Demonstration by methylene blue or Gram staining (IC gonococci, kidney shaped in pairs) Clinical Manifestations in Men Incubation time: 2-10 days Symptoms: 1. acute gonococci urethritis (discomfort, dysuria, purulent discharge) 2. 15% asymptomatic disease spreading 3. Local complications: epididymitis, seminal vesiculitis, prostatitis 4. Chronic gonococci urethritis 5. Extra-genital complications: rectal, oropharyngeal gonorrhea 6. Gonococci ophthalmia neonatorum 1% silver nitrate eye drops Clinical Manifestations in Women Incubation time: days weeks Portal entry: urethral orifice, periurethral crypts, Skenes ducts, Bartholin glands, uterus orifice. Symptoms: 1. Acute salpingitis or dysuria, increased discharge, abnormal bleeding 2. 30-60% asymptomatic or minimally affected carriers 3. PID (pelvic inflam. disease) ascending infection: endometritis, salpingitis, peritonitis infertility Miscellaneous Manifestations Disseminated gonococci infection (arthritis-dermatitis syndrome) 1. 85% women 2. Intermittent febrile attacks 3. Migratory joint pain 4. Skin lesions (isolated flea bite-like papules, hemorrhagic pustules on acral areas) Gonococci ophthalmia neonatorum 1% silver nitrate eye drops.

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Treatment of Gonorrhea Ideal drug for gonorrhea: 1. Cure urethritis 2. Given as a single dose 3. Abort co-incubating syphilis 4. Cure coexisting chlamydial infections Historically: 3x106 IU Penicillin G i.m. + 1 g of Probenecid Ceftriaxone 250 mg IM (3rd gen. Ceph.) Cefixime 400 mg PO (3rd Gen. Ceph) Ofloxacin 400 mg PO (Fluoroquinolones) in a single dose Ciprofloxacin 500 mg PO (Fluoroquinolones) Azithromycin 1 g PO (Macrolide) Chronic gonorrhea: 3-5 days of treatment Follow-up: 1. Microscopic exam 7 days after therapy 2. Syphilis? serology 3. HIV? test Post-gonococci urethritis: 1. Irritated mucous membrane secondary colonization with mycoplasmas and chlamydias 2. Tetracycline for 14 days