Gonorrhea is the second most commonly reported notifiable disease in the United States. Following a dramatic 74% decline in the national rate between 1975 and 1997, the rate of gonorrhea plateaued for several years before increasing again in 2005.  The rate increased for the second consecutive year in 2006 with over 358,000 reported cases, a 5.5% increase over the previous year. Although rates of gonorrhea are essentially similar for men and women, rates for women have been slightly higher than men for the past years. Rates have increased in all regions of the country except the Northeast, and only four states and Puerto Rico had 2006 rates below the HP 2010 target of 19/100,000 population. Rates continue to be highest among adolescents and young adults, and the disparity reported in African Americans is a particular concern (2006 rates were 18 times greater in African Americans than in whites). The continued increase in quinolone-resistant Neisseria gonorrhoeae (QRNG) resulted in a major change in U.S. treatment guidelines.

With respect to the female genital tract, gonorrhea is perhaps the most destructive of the venereal diseases. It may be totally asymptomatic, allowing its victim to unknowingly infect others; it may also produce severe, debilitating pelvic inflammatory disease (P.I.D.), tubo-ovarian abscesses, and tubal occlusion, resulting in sterility. Thus, untreated disease can cause significant long-term psychological ramifications, as well as chronic pelvic pain.

 

 

Contrary to the syphilis spirochete, which has remained susceptible to penicillin, N. gonorrhoeae has a long history of developing resistant strains. The first case of penicillinase-producing Neisseria gonorrhoeae (PPNG) in the United States was reported in 1976 and by 1980 the annual incidence had risen to approximately 1000. By 1987 over 25,000 cases of resistant strains were reported, representing 3.2% of the total cases. In addition to PPNG, other resistant strains have surfaced – chromosomally mediated resistant strains (CMRNG) first identified in 1983, followed by tetracycline resistant forms in 1985. The QRNG, first identified as a problem in Asia and Hawaii in 1991, started to be more prevalent in 1999, spreading first to California and other western states, then to MSM, and more recently to other populations and regions, prompting the CDC in 2007 to remove the fluoroquinolones as a treatment option for gonococcal disease

 

Clinical manifestations

As mentioned earlier, in women the disease may be completely asymptomatic or minimally symptomatic by producing dysuria or a vaginal discharge. The clinical picture depends on the site and severity of the infection. The causative organism; N. gonorrhoeae, primarily infects columnar and pseudostratified epithelium. Because its mode of transmission is by sexual contact, it is therefore not surprising that the major sites of infection are the urogenital, anorectal, and oropharyngeal areas.

Rectal infections may be asymptomatic or may produce symptoms of inflammation of the rectum and anus with a mucopurulent discharge. Although transmitted through sexual activity, patients do not have to participate in actual anal intercourse to develop anorectal infection. It can be transmitted by penile contact in the perineal region, by hand or by toilet paper. Rectal infections are usually associated with genital infections.

Gonococcal pharyngitis is usually asymptomatic but may present as mild sore throat. In some cases the pharynx may be the only site of infection, depending on the person’s sexual practice.

The genitourinary tract is the site of most infections. In the nonpregnant female, the organism can produce inflammation of the lower genital tract glands (Bartholin’s, Skene’s) or ascend by way of the cervix to produce salpingitis, peritonitis, and adnexal abscesses. Pregnant patients rarely have symptomatic intraperitoneal disease; manifestations of acute gonococcal infection in pregnancy usually are limited to the vulvovaginal area.

Cases that are inadequately treated can progress to gonococcal septicemia characterized by low-grade fever, migratory polyarthritis, and dermatitis. The skin lesions can appear anywhere on the body, although the face seems to be spared. They are frequently found on the extremities, sometimes near joints, and progress from a maculopapular rash through a pustular stage to finally become a hemorrhagic-necrotic lesion that eventually disappears altogether. If untreated, the affected joints can proceed to radiologically evident articular destruction. Other less common consequences of gonococcal septicemia include endocarditis, myocarditis, pericarditis and meningitis.

 

Implications for pregnancy

All prenatal patients should be cultured for gonorrhea during their initial visit. In addition, it is highly desirable to reculture prenatal patients in the third trimester, particularly those who are at high risk for STD’s. While tests of cure are not routinely recommended for patients with uncomplicated gonorrhea and resolution of symptoms, pregnant women who receive treatment may benefit from a reculture to verify cure and minimize potential infection of the newborn child.

The two major concerns during pregnancy are maternal septicemia and neonatal infection. For whatever reasons, patients in the second and third trimesters of pregnancy seem to be particularly susceptible to developing disseminated gonococcal infection. Therefore, pregnant patients with positive cervical cultures, highly suspicious skin lesions, or acute arthritic complaints should be evaluated closely to rule out disseminated disease.

Conjunctivitis of the newborn is the most common manifestation of neonatal infection. This is a purulent conjunctivitis that can result in blindness if left untreated. The usual method of infection is by direct contact with the bacteria during a vaginal delivery through an infected cervix. The conjunctival infection can be prevented by applying one of several prophylactic agents to the newborn’s eyes (e.g., tetracycline or erythromycin) and such a procedure should be routine in any hospital that provides maternity care.

Infants can also be infected in utero. If a patient should be unfortunate enough to have premature rupture of the membranes while harboring an active cervical infection, she could develop gonococcal amnionitis and her infant could suffer significant morbidity from widespread disease. These infants and infants born to women with active gonorrhea should receive appropriate antibiotic therapy.

 

Diagnosis

Gram stain

For many years the Gram stain was a valuable aid in the diagnosis of gonorrhea. Due to its low cost, technical simplicity and instantaneous results, it was particularly useful for situations in which patient follow-up was likely to be suboptimal (e.g., emergency rooms). Its limitations included its lack of specificity for the gonococcus and possible errors in staining technique – a technique which fewer and fewer providers are familiar with. The CDC considers the Gram stain to be insufficient to detect infection in endocervical, pharyngeal, and rectal specimens. Given the CDC’s opinion and the advances in diagnostic testing outlined below, the utility of the Gram stain is likely limited to clinical facilities that are geographically isolated or with limited resources.

 

Culture

Culture was the diagnostic test of choice until the development of polymerase chain reaction tests became available.  Although the culture was reportedly 100% specific, its sensitivity was less than ideal, particularly in asymptomatic women.  Additional disadvantages of culture included storage, transport, and 48 hour wait for results. Culture remains, however, the only way to determine antibiotic resistance which assumes increased importance in cases of treatment failures.  Culture remains the best option for the diagnosis of N. gonorrhoeae in non-genital sites (pharynx and rectum) since the non-culture tests are not FDA-cleared for testing in those sites.

NAAT

Nucleic acid amplification techniques (NAATs) use polymerase chain reaction technology to detect fewer organisms.  Although more expensive than other methods, NAATs have high sensitivity and specificity, can provide results in hours, and do not require special handling. They are FDA-cleared for the widest range of specimen types, including endocervical, vaginal, and male urethral swabs, plus female and male urine.  Newer assays have the additional advantage of being able to detect gonorrhea and chlamydia from a single specimen. NAATs cannot provide information on antibiotic resistance; therefore in cases of treatment failures, testing needs to be augmented by use of culture.

 

Treatment

Since this section is devoted to the effects of gonorrhea in pregnancy, the following regimens refer to the treatment of uncomplicated gonococcal infection in pregnancy.  Recommended treatments for P.I.D., pharyngitis, conjunctivitis, and disseminated disease can be found on the Centers for Disease Control and Prevention website. Since the CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections, the only remaining option is Ceftriaxone, 125 mg intramuscularly.

A single dose of azithromycin 2 grams orally has been shown to be effective against uncomplicated gonococcal infections, but the CDC does not recommend its use due to concerns of the development of resistance.  Azithromycin might be considered for patients with documented severe allergic reactions to penicillins or cephalosporins

Approximately 40% of pregnant women infected with N. gonorrhoeae will also be infected with chlamydia. Therefore, it is recommended that patients who are treated for gonorrhea should also be treated for C. trachomatis infection, unless they have a negative chlamydial NAAT result (non-NAAT chlamydial tests are not sensitive enough to forego treatment).