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BASICS

Description

  • Caused by Neisseria gonorrhoeae, a fastidious gram-negative intracellular diplococcus.
  • Presents with conjunctival, pharyngeal, urogenital, or anorectal infection; urogenital most common.
  • Hematogenous spread can cause fever, rash, arthritis, endocarditis, meningitis.
  • Neonatal gonococcal ophthalmia can cause blindness if untreated.

Epidemiology

  • Predominantly affects 15-44 year olds, highest incidence 20-24 years.
  • Male incidence 213/100,000; female 146/100,000 (CDC 2021).
  • Cases increasing since 2012; true prevalence likely higher due to asymptomatic infections.

Etiology and Pathophysiology

  • Infection steps: mucosal attachment, invasion, local proliferation, inflammation or dissemination.
  • Complement deficiencies (C7-C9) increase risk of disseminated disease.

Risk Factors

  • Previous gonorrhea or other STIs
  • Age ≤25 years
  • Sexual contact without barrier protection
  • Multiple/new sexual partners
  • MSM
  • Commercial sex work, drug use
  • Neonates of infected mothers
  • Sexual abuse in children
  • Autoinoculation (finger to eye)

General Prevention

  • Consistent and correct condom use during oral, anal, and vaginal sex.
  • Treat sexual contacts; expedited partner therapy recommended.

Commonly Associated Conditions

  • Other STIs: chlamydia, syphilis, HIV, hepatitis B, herpes

DIAGNOSIS

History

  • Detailed sexual history: number of partners, condom use, recent partner changes.
  • Symptoms typically appear 1-14 days after exposure.
  • Asymptomatic carriage common: 10% men, 20-40% women.
  • Symptomatic:
  • Ocular: discharge, redness, itching
  • Pharyngeal: usually asymptomatic
  • GI: acute diarrhea
  • Urinary: frequency, urgency, dysuria
  • Male: purulent urethral discharge, dysuria, testicular pain
  • Female: endocervical discharge, Bartholin gland swelling, pelvic pain, dyspareunia
  • Rectal (with receptive anal sex): discharge, tenesmus, burning
  • Disseminated infection: fever, chills, rash, arthritis, endocarditis, meningitis

Physical Exam

  • Fever, chills
  • Purulent conjunctivitis, corneal ulceration
  • Exudative pharyngitis (rare)
  • Genitourinary discharge and tenderness
  • Rectal exam may be normal or show discharge
  • Disseminated signs: rash, tenosynovitis, arthritis, endocarditis signs, meningitis signs

Differential Diagnosis

  • Chlamydia trachomatis
  • Other bacterial, viral, or parasitic urethritis/vaginitis
  • Urinary tract infection

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests

  • Nucleic acid amplification test (NAAT): most sensitive and specific.
  • Genital and pharyngeal cultures where appropriate.
  • Gram stain diagnostic in symptomatic men (≥95% sensitivity).
  • Blood and joint fluid cultures in disseminated infection (~50% sensitivity).
  • Screen for coexisting STIs: chlamydia, syphilis, HIV.

Follow-Up and Special Considerations

  • Test of cure not needed for uncomplicated urogenital/rectal infection treated per guidelines.
  • Test of cure recommended for pharyngeal infection at 7-14 days post-treatment.
  • Retest at 3 months due to high reinfection risk.
  • Report cases to public health authorities.

TREATMENT

General Measures

  • Counseling on STI risk reduction and condom use.
  • Suspect sexual abuse in children/adolescents.

Medication

First Line (2021 CDC Guidelines)

  • Uncomplicated urogenital, anorectal, and pharyngeal infection:
  • Ceftriaxone 500 mg IM single dose (1 g if ≥150 kg).
  • If ceftriaxone unavailable, cefixime 800 mg PO single dose (less effective for pharyngeal infection).
  • Treat possible chlamydia co-infection with doxycycline 100 mg PO BID for 7 days unless ruled out.

  • Alternative: gentamicin 240 mg IM once plus azithromycin 2 g PO once.

  • Gonococcal conjunctivitis:

  • Ceftriaxone 1 g IM single dose plus saline eye lavage.

  • Disseminated infections (arthritis, dermatitis, meningitis, endocarditis):

  • Ceftriaxone 1 g IM or IV q24h (or q8h for meningitis) until improvement, then oral therapy for total 1-4 weeks.

Pediatrics

  • Dosing based on weight; ceftriaxone preferred.
  • Ophthalmia neonatorum prophylaxis: erythromycin 0.5% ointment at birth.
  • Neonatal conjunctivitis: ceftriaxone 25-50 mg/kg IM/IV single dose (max 125 mg).

Pregnancy

  • Same regimens as adults.
  • If chlamydia not excluded, add azithromycin 1 g orally single dose or amoxicillin 500 mg TID for 7 days.

Second Line

  • Avoid single 2-g oral azithromycin due to resistance concerns.

Admission Considerations

  • Hematogenous dissemination
  • Severe infant infections (pneumonia, eye infection)

ONGOING CARE

Follow-Up Recommendations

  • USPSTF recommends screening sexually active women ≤24 years and older women at risk.
  • Annual screening of MSM at exposed sites; increase frequency if high risk.
  • Report to public health.
  • Encourage partner notification and expedited partner therapy.
  • Abstinence until 7 days post-treatment and partner treatment.
  • Retesting at 3 months to detect reinfection.

Patient Education

  • Counsel on condom use and STI risk reduction.
  • Emphasize importance of notifying partners.
  • Discuss potential complications and need for follow-up.

Prognosis

  • Complete cure expected with timely and adequate treatment.
  • Reinfection is common; ongoing prevention counseling critical.

Complications

  • Pelvic inflammatory disease, infertility, ectopic pregnancy
  • Urethral stricture
  • Corneal scarring
  • Septic arthritis and joint destruction
  • Cardiac valvular damage

Clinical Pearls

  • Gonococcal antibiotic resistance is a major concern.
  • Always treat for possible chlamydial co-infection.
  • Screen for other STIs routinely in diagnosed patients.

References

  1. Mahapure K, Singh A. A review of recent advances in our understanding of Neisseria gonorrhoeae. Cureus. 2023;15(8):e43464.
  2. CDC. Sexually transmitted infections treatment guidelines, 2021: gonococcal infections. https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm. Accessed Oct 9, 2023.
  3. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC's treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916.
  4. Committee on Gynecologic Practice. ACOG Committee Opinion No. 645: dual therapy for gonococcal infections. Obstet Gynecol. 2015;126(5):e95-e99.
  5. U.S. Preventive Services Task Force. Final recommendation statement: chlamydia and gonorrhea screening. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and-gonorrhea-screening. Accessed Oct 9, 2023.