Kembara Xtra - Medicine - Gonococcal Infection

Kembara Xtra - Medicine - Gonococcal Infection 
A Neisseria gonorrhoeae-related bacterial infection that is spread sexually or vertically:

N. gonorrhoeae is a fastidious gram-negative intracellular diplococcus that can cause infections of the anorectum, pharynx, urogenital tract, or conjunctiva. Hematogenous dissemination causes fever, skin lesions, arthralgias, purulent or sterile arthritis, tenosynovitis, endocarditis, or (rarely) meningitis. Urogenital infections are the most typical type.
Asymptomatic carrier states can affect both sexes. Gonococcal ophthalmia neonatorum, a purulent conjunctivitis, may develop in babies of infected mothers after vaginal delivery; if not treated right once, it could result in blindness.
cardiovascular, musculoskeletal, neurological, reproductive, and skin/exocrine system(s) affected
Alternative words: clap; gonococcal infection

Epidemiology 
92% of occurrences include those aged 15 to 44, with the largest rate occurring in individuals aged 20 to 24.
Men outnumbered women by a ratio of 213/100,000.
Incidence
583,405 cases were reported to the Centers for Disease Control and Prevention (CDC) in 2018.
Prevalence
Prevalence and incidence are essentially comparable. Since more asymptomatic instances exist, the true prevalence is higher:

Rates peaked in the middle of the 1970s and decreased 74% over the following 20 years thanks to a national control effort. Since 2012, rates have been slowly rising.

Male rates are now higher than female rates.

Pathophysiology and Etiology 

Four steps are needed for infection:(i) local penetration or invasion, (ii) local proliferation, (iii) mucosal attachment—bacterial proteins bind to receptors on host cells—(iv) inflammatory response or diffusion. The main way that N. gonorrhoeae spreads is through sexual interaction.
Genetics
A lack of the late complement cascade components (C7–C9) makes a person more susceptible to spreading disease.

Risk factors include a history of gonorrhea infection or other STIs, sexual contact with an infected person without using the proper barrier protection (condom), new or multiple sexual partners, inconsistent condom use, commercial sex work, drug use, infants from an infected mother, children from an infected person abusing them sexually, and autoimmune (finger to eye) immunization.

Prevention 
Condoms must be used properly during oral, anal, and vaginal sex and provide only limited protection.
Treat sexual encounters; take accelerated partner therapy (EPT) into consideration.

Other STIs that are related include chlamydia, syphilis, HIV, hepatitis B, and herpes. 

Diagnoses include sexual history, age at which sexual activity began, STI history, new or recent changes in sexual partners, and contact with commercial sex workers.
- The use of condoms - Menstruation and the potential for pregnancy 10% of males and 20% to 40% of women are asymptomatic.

 If symptomatic, investigate the onset, setting, length, timing, intensity, and related symptoms:
– After exposure, symptoms (if any) usually start to show up 1 to 14 days later.

 Redness, itching, and discharge in the eyes
Urinary symptoms include frequency, urgency, and dysuria. Pharyngeal symptoms include an asymptomatic infection (98%), sore throat, and severe diarrhea.
Urethral signs and symptoms: discharge[A]
Males: testicular pain (1%), proctitis (1%), dysuria (53%), asymptomatic (10%), little to copious purulent urethral discharge (82%),
- Females: vaginal discharge, Bartholin gland swelling, endocervical discharge (96%), asymptomatic cervical infection (20%), abdominal discomfort/tenderness, dyspareunia, cervical motion tenderness, rebound, infertility, and persistent pelvic pain.
Rectal discharge, tenesmus, and rectal burning can occur with either sex with receptive anal contact; they can also be asymptomatic.

Disseminated syndromes: High fevers, chills, malaise, skin rash, and arthralgia/arthritis
Meningitis symptoms include meningeal signs as well as headache, skin lesions, fever, and altered mental status.

clinical assessment 
General: chills and fever
Pharynx: exudative pharyngitis (1%) Ocular: purulent discharge, conjunctivitis, chemosis, eyelid edema, corneal ulceration

Genitourinary (GU): severe diarrhoea, hyperactive bowel noises Urethral discharge and painful testicles in males
- In women, endocervical discharge, Bartholin gland abscess, abdominal discomfort, cervical motion discomfort, and rebound discomfort.

Rectal discharge occurs during either sex during receptive anal intercourse; a rectal exam may be normal.
Disseminated disorders include purulent arthritis, polyarthralgia, and tenosynovitis, which generally affect major joints including the knee, wrist, and ankle.
- Endocarditis: heart murmurs, high fevers, and fast cardiac valve destruction
Meningitis symptoms include meningeal signs as well as headache, skin lesions, fever, and altered mental status.

Multiple Diagnoses 

UTIs, other vaginitis, Chlamydia trachomatis, or urethritis (bacterial, viral, or parasitic)


Laboratory Results 

Initial examinations (lab, imaging)
The most accurate and precise test for N. gonorrhoeae is the nucleic acid amplification test (NAAT).

Other choices:
- Genital practices
- Increase pharyngeal culture in teenagers.
Gram stain, which is advised for urethritis
- Urethral smear, sensitivity in symptomatic men: 95%; endocervical smear, sensitivity in infected women: 40–60%; specificity: 100%
Polymerase chain reaction (PCR) and DNA probes
Specificity: >97%; sensitivity: 92-99% dependent on population; can replace culture
Blood culture is 50% sensitive to illness that has spread widely.
In septic arthritis, joint fluid culture is 50% sensitive.
Check for more STIs, particularly chlamydia, syphilis, and HIV.
Imaging is typically not advised.


Tests in the Future & Special Considerations
When using any of the suggested or alternate regimens to treat uncomplicated urogenital or rectal gonorrhea, a test of cure is not necessary.
- People who have had pharyngeal gonorrhea treated should undergo a cure test with NAAT or culture 7 to 14 days after therapy.
7–12% of gonorrhea patients who get treatment experience reinfection within a year. Regardless of whether the patient thinks their sex partners received treatment, a follow-up test should be done 3 months after treatment. Clinicians should retest within 12 months of the beginning of treatment if retesting at 3 months is not feasible.

Other/Diagnostic Procedures
Performing a culdocentesis may reveal free purulent exudate and provide samples for Gram staining and culture. Gram-stained tissue from skin sores on exposed skin may reveal usual microbes. A fallopian tube abscess or thick, dilated fallopian tubes may be seen on a pelvic ultrasound or CT scan.

Nonpathologic gram-negative diplococci can be identified in extragenital sites, according to the test interpretation. Gram staining of pharyngeal or rectal swabs is not advised due to this.

Suspect sexual abuse in children and teenagers. Management: STI counseling and condom use.

Quinolones are not advised. If treatment fails, examine culture and sensitivities and report to the CDC through local health authorities. Medication. Dual therapy is no longer advised.

If chlamydial infection has not been ruled out, treat the patient with a regimen that is also effective against uncomplicated genital chlamydial infection.

Initial Line
Uncomplicated gonorrheal infections of the pharynx, anorectum, and genitalia (4)Ceftriaxone 500 mg IM in one dose, [A]. Use 1 g IM in a single dosage for people who weigh less than 150 kg (300 lb).
Cefixime 800 mg PO once is an option if IM ceftriaxone is not available. The effectiveness of cefixime as a therapy for pharyngeal gonorrhea is limited.
– Give doxycycline 100 mg orally BID for 7 days if chlamydial infection has not been ruled out.
Conjunctivitis: ceftriaxone, 1 g IM single dose PLUS azithromycin 1 g PO once Alternative: gentamicin 240 mg IM once PLUS azithromycin 2 g PO once Arthritis and arthritis-dermatitis syndrome (1), (2)[A] - Ceftriaxone 1 g IM or IV every 24 hours (q24h) until 24 to 48 hours after improvement starts, at which point PO agent is switched.
Azithromycin 1 g PO once, plus at least a week of antibiotic therapy, must be completed.
- Alternative regimens include switching to a PO drug after administering 1 g of cefotaxime IV every 8 hours for 24 to 48 hours after improvement starts. Azithromycin 1 g PO once, plus at least a week of antibiotic therapy, must be completed.
Ceftizoxime 1 g IV every 8 hours until 24 to 48 hours after improvement starts, at which point switching to a PO agent is recommended. Azithromycin 1 g PO once, plus at least a week of antibiotic therapy, must be completed.
Meningitis and endocarditis: Ceftriaxone 1 to 2 g IV every 12 hours for 10 to 14 days for meningitis; 4 weeks for endocarditis, plus 1 g of azithromycin by mouth once.

Child Safety Considerations

Children over 45 kg: use the same dosage as adults (1), (2)[A]
Ceftriaxone 1 g IM or IV in a single daily dose every 24 hours for 7 days is prescribed for bacterialemia or arthritis.

Uncomplicated urethral, cervical, rectal, or pharyngeal gonococcal infections in children under 45 kg (1), (2)[A]
- A single dosage of ceftriaxone 25 to 50 mg/kg IV or IM, not to exceed 125 mg IM
Ceftriaxone 50 mg/kg IV or IM daily (max dose 1 g) for disseminated infections; bacteremia or arthritis: 7 days; meningitis: 10 to 14 days; endocarditis: 4 weeks; erythromycin 0.5% ophthalmic ointment applied once to each eye immediately following delivery for ophthalmic neonatorum prophylaxis; ceftriaxone 25 to 50 mg/kg IV or IM in 
For a certain diagnosis, conjunctival exudates should be cultured.

Scalp abscesses (caused by scalp electrodes): Ceftriaxone 25 to 50 mg/kg/day IV or IM, given once daily for seven days. Meningitis should be treated for 10 to 14 days if it is present.
Cefotaxime 25 mg/kg IV or IM once every 12 hours for seven days is an alternative. Meningitis should be treated for 10 to 14 days if it is present.
Ceftriaxone 25 to 50 mg/kg IV or IM, not to exceed 125 mg in a single dosage, for asymptomatic children born to women who have untreated gonorrhea.


pregnant women's issues

Women who are pregnant should receive the same care as those indicated above.

Treatment with spectinomycin is an option. Consultation with an infectious disease expert is advised in the absence of spectinomycin or other regimens.

Next Line

Despite the fact that a single 2-g oral dose of azithromycin has been administered in the past, macrolide resistance could result.


Admissions, hematogenously spread illness, newborns with pneumonia or eye infections


Patient Follow-Up Monitoring
(6) U.S. Preventive Services Task Force[A] - Grade B recommendation: Screening for chlamydia and gonorrhea in all sexually active women 24 years of age and younger as well as in older women at increased risk for infection.
- Grade I recommendation: There is insufficient data to suggest screening for chlamydia and gonorrhea in men.
- Inform public health about gonorrhea cases.

● CDC – Regardless of condom use, do a yearly screening for sexually active males who have sex with men (MSM) at the areas of contact (urethra, rectum, and throat). If at greater risk, expand screening to every 3 to 6 months.
 Risk reduction, condom use, future fertility, and comprehensive STI testing counseling
Encourage the patient to inform their partners (for the previous 60 days); think about EPT.

Prognosis 
complete recovery and restoration of function with appropriate and prompt medical care


Complications include: Cardiac valve damage, urethral stricture, ectopic pregnancy, corneal scarring, destruction of joint articular surfaces, infertility, and urethral stricture.
Child Safety Considerations
Patients who are pregnant and have a gonococcal infection run a serious risk of vertical transmission.