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Gonococcal Disease, Emergency Medicine

Basics

Description

• 2nd most frequently reported STD in US:
  • Estimated 820,000 new cases per year
  • <50% reported
  • Highest rates in 15-24-yr-old males and females, African Americans
  • Increasing incidence in men who have sex with men (MSM):
    • Higher in HIV-positive individuals
  • Humans only known host
• Concurrent infection with Chlamydia trachomatis is common
• Affects the urethra, rectum, cervical canal, pharynx, upper female genital tract, and conjunctiva
• Urethritis most common presentation in men
• Often asymptomatic in women

Etiology

Neisseria gonorrhoeae:  

• Gram-negative aerobic diplococci

Diagnosis

Signs and Symptoms

• Cervicitis:
  • Defined as:
    • Mucopurulent endocervical discharge; OR
    • Easily induced endocervical bleeding
  • Most common site of infection
  • Up to 80% asymptomatic
  • Most symptoms nonspecific:
    • Vaginal discharge
    • Menorrhagia
    • Pelvic pain
    • Dyspareunia
    • Frequency and dysuria
• Pelvic inflammatory disease (PID):
  • Up to 20% of untreated cases
  • Lower abdominal pain-most common presenting symptom
  • Other common signs and symptoms:
    • Dyspareunia, abnormal bleeding, abnormal cervical or vaginal discharge
  • Symptoms often occur at onset of menses.
  • Fever (50%)
  • 2/3 have mild, vague symptoms; may go unrecognized
  • Fitz-Hugh-Curtis syndrome: (perihepatitis):
    • 10% occurrence rate
    • Right upper quadrant pain/tenderness
• Bartholin abscess
• Urethritis:
  • Incubation period 2-5 days
  • Symptoms:
    • Penile discharge
    • Dysuria
• Prostatitis-can occur in untreated urethritis
• Epididymitis:
  • Acute, unilateral testicular pain and swelling
• Proctitis:
  • Often asymptomatic
  • Only site of infection in 40% of MSM
  • Rectal infection occurs in 35-50% of women with endocervical infection
  • 3-fold increase in HIV infection risk
  • Symptoms:
    • Perianal pruritus, mucopurulent discharge, mild rectal bleeding, severe rectal pain, tenesmus, and constipation
• Pharyngitis:
  • Sore throat, exudative tonsillitis
• Disseminated gonococcal infections (DGI):
  • Gonococcal bacteremia
  • Arthritis: Dermatitis syndrome:
    • 0.5-3% of untreated mucosal infections
    • Triad of tenosynovitis, dermatitis, and polyarthralgia
    • Fever, chills, malaise
  • Dermatitis:
    • Tender necrotic pustules on an erythematous base, few lesions, begin distally
  • Acute monoarticular or oligoarticular arthritis:
    • Knee most common
    • Warm, erythematous joint with effusion and pain with range of motion
  • Female > male, 3:1:
    • Risk factors: Recent menstruation or recent pregnancy
  • Rare manifestations:
    • Hepatitis
    • Myocarditis
    • Endocarditis
    • Meningitis

Physical Exam

• Cervicitis:
  • Cervical edema, congestion, friability
• PID:
  • Uterine tenderness, adnexal or cervical motion tenderness
• Urethritis:
  • Yellow-white thick discharge, urethral meatal erythema

Essential Workup

• Clinical diagnosis in male gonorrhea:
  • Gram stain 95% sensitive
• Cervical culture in female gonorrhea
• Also test for chlamydia and syphilis

Diagnosis Tests & Interpretation

Lab

• Cultures (gold standard):
  • Thayer-Martin medium
    • Mainstay for blood and synovial fluid
• Gram stain:
  • Intracellular gram-negative diplococci:
    • Approaches 100% sensitive in symptomatic men
• Nucleic acid amplification tests (NAATs):
  • DNA or RNA sequences using polymerase chain reaction (PCR)
  • Many also test for chlamydia
  • Useful in urethral, cervical, and urine specimens
• Pharyngeal/rectal cultures for local symptoms in high-risk individuals
• DGI:
  • Synovial fluid analysis:
    • Neutrophilic leukocytosis, >50,000 cells/mm3
    • Positive cultures when >80,000 cells/mm3
  • 2 or more sets of blood cultures
  • Synovial, skin, urethral or cervical, and rectal cultures:
    • Thayer-Martin media
• PID/lower abdominal pain in female:
  • CBC
  • Urinalysis
  • Pregnancy test
  • Consider pelvic ultrasound for tubo-ovarian abscess
• Rapid plasma reagin (RPR): For associated syphilis

Differential Diagnosis

• Urethritis:
  • Chlamydia
  • Trichomonas
  • UTI
  • Syphilis
• DGI:
  • Bacterial arthritis:
    • Meningococcus (rash)
  • Hepatitis B
  • Connective tissue disease:
    • Reiter syndrome
    • Rheumatoid arthritis
    • Psoriatic arthritis
  • Acute rheumatic fever:
    • Poststreptococcal arthritis
  • Infective endocarditis
  • Others:
    • HIV
    • Secondary syphilis
    • Viral infection
    • Lyme disease (rash)
    • Gout (arthritis)

Treatment

Ed Treatment/Procedures

• Hydration (0.9% NS) for nausea/vomiting
• Treat sexual partner. For expedited partner therapy jurisdiction - www.cdc.gov/std/ept
• Patient with gonorrhea should often be presumptively treated for chlamydial infection.
• Cervical, urethral, and anorectal infection:
  • Ceftriaxone: 250 mg IM once OR
  • Also treat for chlamydia:
    • Azithromycin: 1 g PO once OR
    • Doxycycline: 100 mg PO BID for 7 days
• PID:
  • Outpatient:
    • Ceftriaxone: 250 mg IM once or cefoxitin 2 g IM and probenecid 1 g PO once or another 3rd-generation cephalosporin (ceftizoxime or cefotaxime) + doxycycline 100 mg BID for 14 days with or without metronidazole 500 mg PO BID for 14 days
  • Inpatient:
    • Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + doxycycline 100 mg PO or IV q12h
    • Clindamycin 900 mg IV q8h + gentamicin loading dose (2 mg/kg) followed by (1.5 mg/kg) q8h or 3-5 mg/kg q24h
• Pharyngitis:
  • Ceftriaxone 250 mg IM single dose + treatment for chlamydia
• Epididymitis:
  • Ceftriaxone 250 mg IM once + doxycycline 100 mg BID for 10 days
• Treat sexual partner
• DGI:
  • Ceftriaxone: 1 g IV/IM daily (recommended)
  • Cefotaxime: 1 g IV q8h OR
  • Ceftizoxime: 1 g IV q8h OR
  • 24-48 hr after improvement, additional 7 days with:
    • Cefixime: 400 mg PO BID OR
    • Cefpodoxime: 400 mg PO BID
  • Neonates, incl. gonococcal scalp abscess
    • Ceftriaxone 25-50 mg/kg/d IV/IM for 7 days OR
    • If hyperbilirubinemia-Cefotaxime 25 mg/kg IV/IM q12h for 7 days
• Conjunctivitis:
  • Adults:
    • Ceftriaxone 1 g IM once
  • Ophthalmia neonatorum:
    • Ceftriaxone 25-50 mg/kg IM/IV once
    • Saline irrigation, hospitalize
• Meningitis/endocarditis:
  • Ceftriaxone 1-2 g IV q12h:
    • 10-14 days for meningitis
    • At least 4 wk for endocarditis
• Severe cephalosporin allergy:
  • Consult infectious disease
  • Cephalosporin use postdesensitization best alternative
  • Azithromycin 2 g PO for uncomplicated gonococcal infection:
    • Limit use to prevent resistance

• Gonococcal ophthalmia neonatorum:
  • Mother with genital tract infection
  • Bilateral conjunctivitis 2-5 days postpartum:
    • If untreated, leads to globe perforation

• Gonorrhea: Ceftriaxone/spectinomycin
• Chlamydia: Erythromycin

Follow-Up

Disposition

Admission Criteria
PID-CDC recommendations  

• Severely ill (e.g., nausea, vomiting, and high fever)
• Pregnant
• Does not respond to or cannot take oral medication
• Tubo-ovarian abscess
• Other emergency surgical condition possible (e.g., appendicitis).

Discharge Criteria
Uncomplicated genital, pharyngeal, or conjunctival infection  
Issues for Referral

• Infertility
• Recurrent infection despite multiple therapy

Pearls and Pitfalls

• Epididymitis-rule out torsion
• DGI-strongly consider in young sexually active patient with acute nontraumatic oligoarthritis or tenosynovitis

Additional Reading

• American Academy of Pediatrics. Gonococcal infections. In: Pickering  LK, Baker  CJ, Kimberlin  DW, Long  SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
• Centers for Disease Control and Prevention (CDC). Update to CDCs Sexually transmitted diseases treatment guidelines, 2010: Oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep.  2012;61(31):590-594. http://www.cdc.gov/mmwr/pdf/wk/mm6131.pdf.
• Gonorrhea - CDC Fact Sheet: CS115145, Content updated June 2012. Centers for Disease Control and Prevention. U.S., Department of Health and Human Services, Atlanta. http://www.cdc.gov/std/gonorrhea/gon-fact-sheet-june-2012.pdf.
• Marrazzo  JM, Handsfield  HH, Sparling  PF. Niesseria gonorrhoeae. Chapter 212. In: Mandell: Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. (c)2009.
• Workowski  KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep.  2010;59:1-110. http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.

See Also (Topic, Algorithm, Electronic Media Element)

• Chlamydia
• Urethritis

Codes

ICD9

• 098.0 Gonococcal infection (acute) of lower genitourinary tract
• 098.7 Gonococcal infection of anus and rectum
• 098.15 Gonococcal cervicitis (acute)
• 098.11 Gonococcal cystitis (acute)
• 098.10 Gonococcal infection (acute) of upper genitourinary tract, site unspecified
• 098.12 Gonococcal prostatitis (acute)
• 098.13 Gonococcal epididymo-orchitis (acute)
• 098.14 Gonococcal seminal vesiculitis (acute)
• 098.16 Gonococcal endometritis (acute)
• 098.17 Gonococcal salpingitis, specified as acute
• 098.19 Other gonococcal infection (acute) of upper genitourinary tract
• 098.1 Gonococcal infection (acute) of upper genitourinary tract
• 098.40 Gonococcal conjunctivitis (neonatorum)
• 098.6 Gonococcal infection of pharynx

ICD10

• A54.00 Gonococcal infection of lower genitourinary tract, unsp
• A54.03 Gonococcal cervicitis, unspecified
• A54.6 Gonococcal infection of anus and rectum
• A54.01 Gonococcal cystitis and urethritis, unspecified
• A54.02 Gonococcal vulvovaginitis, unspecified
• A54.09 Other gonococcal infection of lower genitourinary tract
• A54.0 Gonococcal infection of lower genitourinary tract without periurethral or accessory gland abscess
• A54.22 Gonococcal prostatitis
• A54.24 Gonococcal female pelvic inflammatory disease
• A54.29 Other gonococcal genitourinary infections
• A54.31 Gonococcal conjunctivitis
• A54.5 Gonococcal pharyngitis

SNOMED

• 17305005 acute gonorrhea of genitourinary tract (disorder)
• 42746002 Gonorrhea of rectum (disorder)
• 20943002 Acute gonococcal cervicitis (disorder)
• 236682002 Gonococcal urethritis (disorder)
• 186931002 Gonococcal anal infection (disorder)
• 197967000 Gonococcal prostatitis (disorder)
• 231858009 Gonococcal conjunctivitis (disorder)
• 236772009 Gonococcal epididymo-orchitis
• 240581006 gonococcal female pelvic infection (disorder)
• 74372003 Gonorrhea of pharynx (disorder)

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