Gonorrhea Curriculum
Gonorrhea
Neisseria gonorrhoeae
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Gonorrhea Curriculum
Learning Objectives
Upon completion of this content, the learner will be able to
Describe the epidemiology of gonorrhea in the U.S.
Describe the pathogenesis of Neisseria gonorrhoeae.
Discuss the clinical manifestations of gonorrhea.
Identify common methods used in the diagnosis of gonorrhea.
List CDC-recommended treatment regimens for gonorrhea.
Summarize appropriate prevention counseling messages for
patients with gonorrhea.
Describe public health measures for the prevention of
gonorrhea.
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Gonorrhea Curriculum
Lessons
I. Epidemiology: Disease in the U.S.
II. Pathogenesis
III. Clinical manifestations
IV. Diagnosis
V. Patient management
VI. Prevention
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Gonorrhea Curriculum
Lesson I:
Epidemiology: Disease in the U.S.
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Gonorrhea Curriculum Epidemiology
Incidence and Prevalence
Significant public health problem in U.S.
Number of reported cases underestimates
incidence
Incidence remains high in some groups
defined by geography, age, race/ethnicity,
or sexual risk behavior
Increasing proportion of gonococcal
infections caused by resistant organisms
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Gonorrhea Curriculum
GonorrheaRates, United States, 19412011
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Gonorrhea Curriculum
GonorrheaRates by State, United States and
Outlying Areas, 2011
NOTE: The total rate of gonorrhea for the United States and outlying7 area (Guam,
Puerto Rico, and Virgin Islands) was 103.1 per 100,000 population.
Gonorrhea Curriculum
GonorrheaRates by Sex, United States,
19912011
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Gonorrhea Curriculum
GonorrheaRates by Race/Ethnicity,
United States, 20022011
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Gonorrhea Curriculum
GonorrheaRates by Age and Sex,
United States, 2011
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Gonorrhea Curriculum Epidemiology
Risk Factors
Multiple or new sex partners or inconsistent
condom use
Urban residence in areas with disease
prevalence
Adolescent, females particularly
Lower socio-economic status
Use of drugs
Exchange of sex for drugs or money
African American
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Gonorrhea Curriculum Epidemiology
Transmission
Efficiently transmitted by
Male to female via semen
Vagina to male urethra
Rectal intercourse
Fellatio (pharyngeal infection)
Perinatal transmission (mother to infant)
Gonorrhea associated with increased
transmission of and susceptibility to HIV
infection
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Gonorrhea Curriculum
Lesson II: Pathogenesis
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Gonorrhea Curriculum Pathogenesis
Microbiology/Pathology
Etiologic agent: Neisseria gonorrhoeae
Gram-negative intracellular diplococcus
Infects mucus-secreting epithelial cells
Evades host response through
alteration of surface structures
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Gonorrhea Curriculum Pathogenesis
Gonorrhea: Gram Stain of
Urethral Discharge
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Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Gonorrhea Curriculum
Lesson III: Clinical
Manifestations
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Gonorrhea Curriculum Clinical Manifestations
Genital Infection in Men
Urethritis Inflammation of urethra
Epididymitis Inflammation of the
epididymis
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Gonorrhea Curriculum Clinical Manifestations
Male Urethritis
Symptoms
Typically purulent or mucopurulent urethral
discharge
Often accompanied by dysuria
Discharge may be clear or cloudy
Asymptomatic in a minority of cases
Incubation period: usually 1-14 days for
symptomatic disease, but may be longer
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Gonorrhea Curriculum Clinical Manifestations
Gonococcal Urethritis:
Purulent Discharge
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Source: Seattle STD/HIV Prevention Training Center at the University of Washington:
Connie Celum and Walter Stamm
Gonorrhea Curriculum Clinical Manifestations
Epididymitis
Symptoms: unilateral testicular pain and
swelling
Infrequent, but most common local
complication in males
Usually associated with overt or
subclinical urethritis
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Gonorrhea Curriculum Clinical Manifestations
Swollen or Tender Testicle
(Epididymitis)
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Source: Seattle STD/HIV Prevention Training Center at the University of Washington
Gonorrhea Curriculum Clinical Manifestations
Genital Infection in Women
Most infections are asymptomatic
Cervicitis inflammation of the cervix
Urethritis inflammation of the urethra
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Gonorrhea Curriculum Clinical Manifestations
Cervicitis
Non-specific symptoms: abnormal vaginal
discharge, intermenstrual bleeding, dysuria,
lower abdominal pain, or dyspareunia
Clinical findings: mucopurulent or purulent
cervical discharge, easily induced cervical
bleeding
At least 50% of women with clinical
cervicitis have no symptoms
Incubation period unclear, but symptoms
may occur within 10 days of infection
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Gonorrhea Curriculum Clinical Manifestations
Gonococcal Cervicitis
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Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Gonorrhea Curriculum Clinical Manifestations
Urethritis
Symptoms: dysuria, however, most
women are asymptomatic
70%90% of women with cervical
gonococcal infection may have urethral
infection
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Gonorrhea Curriculum Clinical Manifestations
Complications in Women
Accessory gland infection
Bartholins glands
Skenes glands
Pelvic Inflammatory Disease (PID)
May be asymptomatic
May present with lower abdominal pain,
discharge, dyspareunia, irregular menstrual
bleeding and fever
Fitz-Hugh-Curtis Syndrome
Perihepatitis
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Gonorrhea Curriculum Clinical Manifestations
Bartholins Abscess
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Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Gonorrhea Curriculum Clinical Manifestations
Syndromes in Men and Women
Anorectal infection
Usually acquired by anal intercourse
Usually asymptomatic
Symptoms: anal irritation, painful defecation, constipation, scant rectal
bleeding, painless mucopurulent discharge, tenesmus, and anal pruritus
Evaluate utilizing an anoscopic examination
Signs: mucosa may appear normal, or purulent discharge, erythema, or easily
induced bleeding may be observed with anoscopic exam
Pharyngeal infection
May be sole site of infection if oral-genital contact is the only exposure
Most often asymptomatic, but symptoms, if present, may include pharyngitis,
tonsillitis, fever, and cervical adenitis
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Gonorrhea Curriculum Clinical Manifestations
Syndromes in Men and Women
(continued)
Conjunctivitis
Usually a result of autoinoculation in adults
Symptoms/signs: eye irritation with purulent conjunctival exudate
Disseminated gonococcal infection (DGI)
Systemic gonococcal infection
Occurs infrequently. More common in women than in men
Associated with a gonococcal strain that produces bacteremia without
associated urogenital symptoms
Clinical manifestations: skin lesions, arthralgias, tenosynovitis,
arthritis, hepatitis, myocarditis, endocarditis,and meningitis
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Gonorrhea Curriculum Clinical Manifestations
Gonococcal Ophthalmia
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Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Gonorrhea Curriculum Clinical Manifestations
Disseminated Gonorrhea
Skin Lesion on Foot
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Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides
Gonorrhea Curriculum Clinical Manifestations
Gonococcal Infection in
Children
Perinatal: infections of the conjunctiva, pharynx,
respiratory tract or anal canal
Older children (>1 year): considered possible
evidence of sexual abuse
Vulvovaginitis, not cervicitis, in prepubesient girls
Anorectum or pharynx more commonly infected
in boys than urethra
Because of legal implications, culture remains the
preferred method of diagnosis 32
Gonorrhea Curriculum
Lesson IV: Diagnosis
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Gonorrhea Curriculum Diagnosis
Diagnostic Methods
Culture tests
Advantages: low cost, suitable for a variety of
specimen sites, antimicrobial susceptibility can be
performed
Anatomic sites to test: in response to exposure
history in persons at significant risk of gonococcal
infection, complaints, or clinical findings
In men: urethra in all men; pharynx and rectum, depending
on exposure history or symptoms
In women: cervix should be tested; pharynx and rectum
depending on symptoms and exposure history; vagina may
be tested if cervix is absent; Bartholins or Skenes glands
may be cultured if overt exudate is expressed
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Gonorrhea Curriculum Diagnosis
Diagnostic Methods (continued)
Non-culture tests
Amplified tests (NAATs)
Polymerase chain reaction (PCR) (Roche
Amplicor)
Transcription-mediated amplification (TMA) (Gen-
Probe Aptima)
Strand displacement amplification (SDA) (Becton-
Dickinson BD ProbeTec ET)
Non-amplified tests
DNA probe (Gen-Probe PACE 2, Digene Hybrid
Capture II)
Gram-stained smear
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Gonorrhea Curriculum Diagnosis
Clinical Considerations
In cases of suspected sexual abuse
Adults
NAATs are preferred for diagnostic evaluation
of sexual assault regardless of penetration
Children
Culture remains the preferred method for
urethral specimens or urine from boys and for
extragenital specimens for all children
NAATs can be used as an alternative to culture
with vaginal specimens or urine from girls
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Gonorrhea Curriculum
Lesson V: Patient
Management
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Gonorrhea Curriculum Management
Antimicrobial Susceptibility of
N. gonorrhoeae
Fluoroquinolone resistance is widely
disseminated throughout the U.S. and the
world
Approximately 25% of isolates are resistance
to penicillin or tetracycline or both
In 2011, 0.3% of isolates showed decreased
susceptibility to azithromycin, down from
0.5% in 2010.
Sporadic cases of decreased susceptibility to
ceftriaxone and cefixime have been reported
recently 38
Gonorrhea Curriculum
Percentage of Neisseria gonorrhoeae Isolates that are
Ciprofloxacin-Resistant by Sex of Sex Partner, Gonococcal
Isolate Surveillance Project (GISP), 19952011
*MSM=men who have sex with men; MSW=men who have sex with women only. 39
Gonorrhea Curriculum
Distribution of Minimum Inhibitory Concentrations (MICs)
of Cefixime Among Neisseria gonorrhoeae Isolates,
Gonococcal Isolate Surveillance Project (GISP), 20092011
NOTE: Isolates were not tested for cefixime susceptibility in 2007 and 2008
Gonorrhea Curriculum
Distribution of Minimum Inhibitory Concentrations (MICs)
of Ceftriaxone Among Neisseria gonorrhoeae Isolates,
Gonococcal Isolate Surveillance Project (GISP), 20072011
Gonorrhea Curriculum Management
Treatment for Uncomplicated
Gonococcal Infections of the Cervix,
Urethra, and Rectum
Recommended
Ceftriaxone 250 mg IM Once
PLUS
Azithromycin 1g Orally Once
OR
Twice a day for
Doxycycline 100 mg Orally
7 days
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Quinolones are no longer recommended in the United States for the treatment of gonorrhea and
associated conditions, such as PID
Gonorrhea Curriculum Management
Treatment for Uncomplicated
Gonococcal Infections of the Cervix,
Urethra, and Rectum
Alternative 1: If Ceftriaxone is not available
Cefixime 400 mg Orally Once
PLUS
Azithromycin 1g Orally Once
OR
Twice a day for
Doxycycline 100 mg Orally
7 days
PLUS
Test of cure in 1 week
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Gonorrhea Curriculum Management
Treatment for Uncomplicated
Gonococcal Infections of the Cervix,
Urethra, and Rectum
Alternative 2: If patient is cephalosporin-allergic
Azithromycin 2g Orally Once
PLUS
Test of cure in 1 week
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Gonorrhea Curriculum Management
Treatment for Uncomplicated
Gonococcal Infections of the Pharynx
Ceftriaxone 250 mg IM Once
PLUS
Once
Azithromycin 1g Orally
OR
Twice a day for
Doxycycline 100 mg Orally
7 days
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Gonorrhea Curriculum Management
Special Considerations:
Pregnancy
Treat with recommended cephalosporin-based
combination therapy
If cephalosporin is not tolerated, treat with
azithromycin 2 g orally. A test of cure should be
performed 1 week after treatment
Pregnant women should not be treated with
quinolones or tetracyclines. Spectinomycin is not
commercially available
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Gonorrhea Curriculum Management
Penicillin-Allergic
Azithromycin 2 g orally
Plus test of cure in 1 week
Desensitization is impractical in most
settings
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Gonorrhea Curriculum Management
Follow-Up
A test of cure is not recommended if
recommended regimen is administered
A test of cure is recommended if an alternative
regimen is administered
If symptoms persist, perform culture for N.
gonorrhoeae
Any gonococci isolated should be tested for
antimicrobial susceptibility at site of
exposure
Repeat testing in 3 months
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Gonorrhea Curriculum
Lesson VI: Prevention
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Gonorrhea Curriculum Prevention
Screening
Pregnancy:
A test for N. gonorrhoeae should be performed at the1st
prenatal visit for women at risk or those living in an area in
which the prevalence of N. gonorrhoeae is high
Repeat test in the 3rd trimester for those at continued risk
U.S. Preventive Service Task Force recommends screening all sexually
active women for gonorrhea infection if they are at increased risk of
infection
Sexually active men who have sex with men: CDC recommends
screening at least annually at all anatomic sites of exposure
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Gonorrhea Curriculum Prevention
Partner Management
Evaluate and treat all sex partners for
N. gonorrhoeae and C. trachomatis infections, if
contact was within 60 days of symptoms or
diagnosis
If a patients last sexual intercourse was >60
days before onset of symptoms or diagnosis, the
patients most recent sex partner should be
treated
Avoid sexual intercourse until therapy is
completed and both partners no longer have
symptoms
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Gonorrhea Curriculum Prevention
Reporting
Laws and regulations in all states
require that persons diagnosed with
gonorrhea are reported to public health
authorities by clinicians, labs, or both
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Gonorrhea Curriculum Prevention
Patient Counseling/Education
Nature of disease
Usually symptomatic in males and asymptomatic in
females
Untreated infections can result in PID, infertility, and
ectopic pregnancy in women and epididymitis in men
Transmission issues
Efficiently transmitted
Risk reduction
Utilize prevention strategies
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Gonorrhea Curriculum
Case Study
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Gonorrhea Curriculum Case Study
History: Robert Forbes
33-year-old male who presents to his doctor reporting
a purulent urethral discharge and dysuria for 3 days.
Lives in Dallas with history of travel to Las Vegas 3
weeks ago.
New female sex partner (Laura) for 2 months. They
have unprotected vaginal intercourse 4 times/week, the
last time being 2 days ago. No oral or rectal sex.
Also had a one-time sexual encounter with a woman
he met in Las Vegas 3 weeks ago (Monica). They had
oral and vaginal sex. No condoms used.
No history of urethral discharge or STDs, no sore
throat or rectal discomfort. Negative HIV test 1 year
ago.
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Gonorrhea Curriculum Case Study
Physical Exam
Vital signs: blood pressure 98/72, pulse 68,
respiration 14, temperature 37.2 C
Cooperative, good historian
Chest, heart, musculoskeletal, and abdominal
exams within normal limits
No flank pain on percussion, normal rectal
exam, no sores or rashes
The genital exam reveals a reddened urethral
meatus with a purulent discharge, without
lesions or lymphadenopathy
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Gonorrhea Curriculum Case Study
Questions
1. What should be included in the
differential diagnosis?
2. Which laboratory tests are appropriate
to order or perform?
3. What is the appropriate treatment
regimen?
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Gonorrhea Curriculum Case Study
Laboratory Results
Results of laboratory tests:
Urethral and pharyngeal culture: showed growth of a
Gram-negative diplococcus that was oxidase-positive.
Biochemical and FA conjugate testing confirmed this
isolate to be N. gonorrhoeae.
NAAT for chlamydia: negative
RPR: nonreactive
HIV antibody test: negative
4) What is the diagnosis, based on all available
information?
5) Who is responsible for reporting this case to the local
health department?
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Gonorrhea Curriculum Case Study
Partner Management
Roberts sex partners within 6) Laura was examined
the past 3 months: and her lab results
Laura: Last exposure - came back negative
Unprotected vaginal sex 2
days ago for gonorrhea and
Monica: Last exposure - chlamydia. How
Unprotected oral (Monica should Laura be
performed fellatio) and managed?
vaginal sex 3 weeks ago
while he was in Las Vegas 7) What tests should
Jerilyn: Last exposure - Jerilyn and Monica
Unprotected vaginal sex 3 have?
months ago
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Gonorrhea Curriculum Case Study
Follow-Up
Robert returns 4 months later for an employer-
sponsored flu shot. He took his medications as
directed, is asymptomatic, and has had no sex
partners since his office visit to you.
8) Does Robert need repeat testing for
gonorrhea?
9) What are appropriate prevention counseling
messages for Robert?
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