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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

- 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

- 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

- Rare manifestations: - Hepatitis - Myocarditis - Endocarditis - Meningitis

- Cultures (gold standard): - Thayer-Martin medium - Mainstay for blood and synovial fluid

- PID/lower abdominal pain in female: - CBC - Urinalysis - Pregnancy test - Consider pelvic ultrasound for tubo-ovarian abscess

- Urethritis: - Chlamydia - Trichomonas - UTI - Syphilis

- DGI: - Bacterial arthritis: - Hepatitis B - Connective tissue disease: - Reiter syndrome - Rheumatoid arthritis - Psoriatic arthritis

- 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

  • 2nd most frequently reported STD in US:Estimated 820,000 new cases per year<50% reportedHighest rates in 15-24-yr-old males and females, African AmericansIncreasing incidence in men who have sex with men (MSM):Higher in HIV-positive individualsHumans 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; OREasily induced endocervical bleedingMost common site of infectionUp to 80% asymptomaticMost symptoms nonspecific:Vaginal dischargeMenorrhagiaPelvic painDyspareuniaFrequency and dysuria
  • Pelvic inflammatory disease (PID):Up to 20% of untreated casesLower abdominal pain-most common presenting symptomOther common signs and symptoms:Dyspareunia, abnormal bleeding, abnormal cervical or vaginal dischargeSymptoms often occur at onset of menses.Fever (50%)2/3 have mild, vague symptoms; may go unrecognizedFitz-Hugh-Curtis syndrome: (perihepatitis):10% occurrence rateRight upper quadrant pain/tenderness
  • Bartholin abscess
  • Urethritis:Incubation period 2-5 daysSymptoms:
  • Prostatitis-can occur in untreated urethritis
  • Epididymitis:Acute, unilateral testicular pain and swelling
  • Proctitis:Often asymptomaticOnly site of infection in 40% of MSMRectal infection occurs in 35-50% of women with endocervical infection3-fold increase in HIV infection riskSymptoms:Perianal pruritus, mucopurulent discharge, mild rectal bleeding, severe rectal pain, tenesmus, and constipation
  • Pharyngitis:Sore throat, exudative tonsillitis
  • Disseminated gonococcal infections (DGI):Gonococcal bacteremiaArthritis: Dermatitis syndrome:0.5-3% of untreated mucosal infectionsTriad of tenosynovitis, dermatitis, and polyarthralgiaFever, chills, malaiseDermatitis:Tender necrotic pustules on an erythematous base, few lesions, begin distallyAcute monoarticular or oligoarticular arthritis:Knee most commonWarm, erythematous joint with effusion and pain with range of motionFemale > male, 3:1:Risk factors: Recent menstruation or recent pregnancyRare manifestations:HepatitisMyocarditisEndocarditisMeningitis

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:
  • Cervical culture in female gonorrhea
  • Also test for chlamydia and syphilis

Diagnosis Tests & Interpretation

Lab

  • Cultures (gold standard):Thayer-Martin mediumMainstay 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 chlamydiaUseful 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/mm3Positive cultures when >80,000 cells/mm32 or more sets of blood culturesSynovial, skin, urethral or cervical, and rectal cultures:
  • PID/lower abdominal pain in female:CBCUrinalysisPregnancy testConsider pelvic ultrasound for tubo-ovarian abscess
  • Rapid plasma reagin (RPR): For associated syphilis

Differential Diagnosis

  • Urethritis:ChlamydiaTrichomonasUTISyphilis
  • DGI:Bacterial arthritis:Hepatitis BConnective tissue disease:Reiter syndromeRheumatoid arthritisPsoriatic arthritisAcute rheumatic fever:Poststreptococcal arthritisInfective endocarditisOthers:HIVSecondary syphilisViral infectionLyme 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 ORAlso treat for chlamydia:Azithromycin: 1 g PO once ORDoxycycline: 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 daysInpatient:Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + doxycycline 100 mg PO or IV q12hClindamycin 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 ORCeftizoxime: 1 g IV q8h OR24-48 hr after improvement, additional 7 days with:Cefixime: 400 mg PO BID ORCefpodoxime: 400 mg PO BIDNeonates, incl. gonococcal scalp abscessCeftriaxone 25-50 mg/kg/d IV/IM for 7 days ORIf hyperbilirubinemia-Cefotaxime 25 mg/kg IV/IM q12h for 7 days
  • Conjunctivitis:Adults:Ophthalmia neonatorum:Ceftriaxone 25-50 mg/kg IM/IV onceSaline irrigation, hospitalize
  • Meningitis/endocarditis:Ceftriaxone 1-2 g IV q12h:10-14 days for meningitisAt least 4 wk for endocarditis
  • Severe cephalosporin allergy:Consult infectious diseaseCephalosporin use postdesensitization best alternativeAzithromycin 2 g PO for uncomplicated gonococcal infection:Limit use to prevent resistance
  • Gonococcal ophthalmia neonatorum:Mother with genital tract infectionBilateral 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)

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)