Scientific Presentation
on
Gonorrhoea
Speaker:
Dr. Md. Shahidul Islam
Assistant Professor of Dermatology & VD,
CBMC’B

Cha...
Introduction


Gonorrhea has affected humans for centuries and remains common.



Worldwide, an estimated 106.1 million ...
History






Neisseria gonorrhoeae described by Albert
Neisser in 1879
Observed in smears of purulent exudates of
uret...
Risk Factors








Multiple or new sex partners
Inconsistent condom use
Urban residence
Adolescents, females part...
Transmission


Efficiently transmitted by sexual contact
– Male to female via semen
– Female to male urethra
– Anal inter...
PATHOGENESIS :











Gonococci  get attached by Pilli  to columnar epithelial cells
(urethra )

Produce mar...




Urethritis is uncommon in females
because of small urethra
Both transitional and stratified
squamous epithelium are ...
Microbiology


Etiologic agent: Neisseria

gonorrhoeae


Gram-negative intracellular
diplococcus



Infects mucus-secre...
Gonorrhea: Gram’s Stain
of
Urethral Discharge
Genital Infection in Men


Urethritis – Inflammation of urethra



Epididymitis – Inflammation of the
epididymis
Male Urethritis


Symptoms
– Typically purulent or mucopurulent urethral
discharge
– Often accompanied by dysuria
– Disch...
Gonococcal Urethritis:
Purulent Discharge
Epididymitis






Symptoms: unilateral testicular pain and
swelling
Infrequent, but most common local
complication in ...
Swollen or Tender
Testicles (Epididymitis)
LOCAL









COMPLICATIONS in Male

Urethral stricture
Periurethral abscess
Prostatitis
Prostatic abscess
Seminal...
Genital Infection in Women


Most infections are asymptomatic



Cervicitis – inflammation of the cervix



Urethritis ...
Cervicitis


Non-specific symptoms: abnormal vaginal discharge,
intermenstrual bleeding, dysuria, lower abdominal pain,
o...
Gonococcal Cervicitis
Urethritis


Symptoms: dysuria, however, most
women are asymptomatic



40%-60% of women with cervical
gonococcal infect...
LOCAL COMPLICATIONS
(Female)


Salpingo Oophoritis--- fallopian tube
block



Bartholein abscess



Pelvic peritonitis
Bartholin’s Abscess
Gonococcal complications in
Pregnancy




Postpartum endometritis
Septic abortions
Post-abortal PID

Possible role in:
...
Gonorrhea Infection in
Children


Perinatal: infections of the
conjunctiva, pharynx, respiratory
tract



Older children...
Gonococcal Ophthalmia
LOCAL COMPLICATIONS
BOTH SEX


Proctitis (Anogenital sex)



Pharyngitis (Oragenital sex )



Ophthalmia neonatum
Remote / Metastatic
complications (Both sex)






Septicaemia/ Disseminated
Gonococcal Infection (DGI)
Gonococcal art...
Disseminated Gonorrhea—
Skin Lesion
Diagnostic Methods
1. Gram’s stain for microscopic
examination
–
P/S or urethral discharge
(male)
–

Cervical swab (female...
Gonorrhea Diagnostic
Tests
Gram stain

Sensitivity
90-95%

(male urethra exudate)

DNA probe
Culture

85-90%
80-95%

NAATs...
GC Gram Stain








In symptomatic male urethritis:
– >95% sensitivity and specificity: reliable
to diagnose and ex...


Specific diagnosis of infection with N.
gonorrhoeae can be performed by testing
endocervical, vaginal, urethral (men on...
• NAATs allow testing of the widest variety of
specimen types including endocervical swabs,
vaginal swabs, urethral swabs ...
Gram Stain for GC:
Urethral Smear




Numerous
PMNs
Gram
negative
intracellular
diplococci
Gram Stain for GC:
Cervical Smear


PMN with
Gram
negative
intracellular
diplococci
GC Culture







Requires selective media with antibiotics to
inhibit competing bacteria (Modified Thayer
Martin Medi...
GC Culture Candle Jar
GC Culture Specimen
Streaking
Cervical and Urethral
GC Culture After 24
Hours
Management


It is important to receive treatment for gonorrhoea quickly.



Patients with gonorrhea frequently also hav...


Treatment depends on the site of involvement.
Infections that have spread beyond the primary
site of infection like DGI...


Single-dose cephalosporin regimens
(Both sex partners)
Inj.Ceftriaxon (Ceftron) I/V or I/M

or
– Inj Spectinomycin 2 g
...


Fluoroquinolones are no longer
recommended for therapy for
gonorrhea acquired in Asia, the
Pacific Islands (including H...
Pregnant women should not be
treated with quinolones .Treat
with alternate cephalosporin
 If cephalosporin is not
tolerat...
Co-treatment for
Chlamydia


If chlamydial infection is not ruled out:

Tab.Azithromycin 1 gm (Tab.Zimax-500mg) Orally
On...
DGI Treatment
Initial IV Therapy

Begin IV therapy for 24-48 hrs, switch to oral therapy for a
total of 1 week

Recommende...
DGI Treatment

Subsequent Oral Therapy
Oral therapy for total treatment of 1 week:

Recommended Regimes:
– Cefixime 400 mg...
Follow-Up




A test of cure is not
recommended if a recommended
regimen is administered.
If symptoms persist, perform
c...
Prevention strategies:







Health promotion, education &
counseling
Increased access to condoms
Early detection t...
Home messages:
– Gonorrhoea is usually
symptomatic in males and
asymptomatic in females
– Untreated infections can result ...






It can be acquired from asymptomatic
partner.
Both sex partners need to be treated at a
time.
Over diagnosis of...


All persons found to have who have
gonorrhea also should be tested for other
STDs, including chlamydia, syphilis, and
H...
Acknowledgements








Prof. Hasibur Rahman
Dr.Hadiuzzaman
Dr.Nahida Islam Nipa
Dr.Sabrina Alam Mumu
Dr. Atia Afro...
Gonorrhoea Update
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Gonorrhoea Update

  1. 1. Scientific Presentation on Gonorrhoea Speaker: Dr. Md. Shahidul Islam Assistant Professor of Dermatology & VD, CBMC’B Chairperson: Professor. Hasibur Rahman Head of the Department of Dermatology & VD, CBMC’B
  2. 2. Introduction  Gonorrhea has affected humans for centuries and remains common.  Worldwide, an estimated 106.1 million cases occur annually.  Significant public health problems are now-a-days occurring in Bangladesh  Increasing proportion of gonococcal infections caused by resistant organisms  Gono  seeds, rhoea  flow. So gonorrhoea means abnormal flow of semen
  3. 3. History    Neisseria gonorrhoeae described by Albert Neisser in 1879 Observed in smears of purulent exudates of urethritis, cervicitis, opthalmia neonatorum Thayer Martin medium enhanced isolation of gonococcus in 1960
  4. 4. Risk Factors        Multiple or new sex partners Inconsistent condom use Urban residence Adolescents, females particularly Lower socio-economic status Drug addicts Exchange of sex for drugs or money
  5. 5. Transmission  Efficiently transmitted by sexual contact – Male to female via semen – Female to male urethra – Anal intercourse – Oro-genital sex (pharyngeal infection) – Peri-natal transmission (mother to infant)  Gonorrhea associated with increased transmission and susceptibility to HIV infection
  6. 6. PATHOGENESIS :        Gonococci  get attached by Pilli  to columnar epithelial cells (urethra )  Produce marked polymorphonuclear response in the submucosa (Anterior urethra )  Purulent exudates fill up the anterior urethra (male )  Inflammatory process extends to the posterior urethra  Granular tissue formed in mucosa and submucosa  Eventual fibrosis and scarring  Stricture urethra ( complication )
  7. 7.   Urethritis is uncommon in females because of small urethra Both transitional and stratified squamous epithelium are highly resistant to the organism, therefore in adult vaginal canal is not affected
  8. 8. Microbiology  Etiologic agent: Neisseria gonorrhoeae  Gram-negative intracellular diplococcus  Infects mucus-secreting epithelial cells
  9. 9. Gonorrhea: Gram’s Stain of Urethral Discharge
  10. 10. Genital Infection in Men  Urethritis – Inflammation of urethra  Epididymitis – Inflammation of the epididymis
  11. 11. Male Urethritis  Symptoms – Typically purulent or mucopurulent urethral discharge – Often accompanied by dysuria – Discharge may be clear or cloudy   Asymptomatic in 10% of cases Incubation period: usually 1-14 days for symptomatic disease, but may be longer
  12. 12. Gonococcal Urethritis: Purulent Discharge
  13. 13. Epididymitis    Symptoms: unilateral testicular pain and swelling Infrequent, but most common local complication in males Usually associated with overt or subclinical urethritis
  14. 14. Swollen or Tender Testicles (Epididymitis)
  15. 15. LOCAL        COMPLICATIONS in Male Urethral stricture Periurethral abscess Prostatitis Prostatic abscess Seminal vasiculitis Epidedymitis Orchitis
  16. 16. Genital Infection in Women  Most infections are asymptomatic  Cervicitis – inflammation of the cervix  Urethritis – inflammation of the urethra
  17. 17. Cervicitis  Non-specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia  Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding  50% of women with clinical cervicitis have no symptoms  Incubation period unclear, but symptoms may occur within 10 days of infection
  18. 18. Gonococcal Cervicitis
  19. 19. Urethritis  Symptoms: dysuria, however, most women are asymptomatic  40%-60% of women with cervical gonococcal infection may have urethral infection
  20. 20. LOCAL COMPLICATIONS (Female)  Salpingo Oophoritis--- fallopian tube block  Bartholein abscess  Pelvic peritonitis
  21. 21. Bartholin’s Abscess
  22. 22. Gonococcal complications in Pregnancy    Postpartum endometritis Septic abortions Post-abortal PID Possible role in:  Gestational bleeding  Preterm labor and delivery  Premature rupture of membranes
  23. 23. Gonorrhea Infection in Children  Perinatal: infections of the conjunctiva, pharynx, respiratory tract  Older children (>1 year): considered possible evidence of sexual abuse
  24. 24. Gonococcal Ophthalmia
  25. 25. LOCAL COMPLICATIONS BOTH SEX  Proctitis (Anogenital sex)  Pharyngitis (Oragenital sex )  Ophthalmia neonatum
  26. 26. Remote / Metastatic complications (Both sex)     Septicaemia/ Disseminated Gonococcal Infection (DGI) Gonococcal arthritis Perihepatitis Gonococcal Dermatitis
  27. 27. Disseminated Gonorrhea— Skin Lesion
  28. 28. Diagnostic Methods 1. Gram’s stain for microscopic examination – P/S or urethral discharge (male) – Cervical swab (female) 2. Culture tests 3. Others Polymerase chain reaction (PCR)  DNA probe  NAATs 
  29. 29. Gonorrhea Diagnostic Tests Gram stain Sensitivity 90-95% (male urethra exudate) DNA probe Culture 85-90% 80-95% NAATs * 90-95% Specificity > 95% > 95% > 99% > 98% * Able to use URINE specimens
  30. 30. GC Gram Stain      In symptomatic male urethritis: – >95% sensitivity and specificity: reliable to diagnose and exclude GC In cervicitis: – 50-70%sensitivity, 95% specificity Not useful in pharyngeal infections Accessory gland infection: similar to male urethritis Proctitis: similar to cervicitis
  31. 31.  Specific diagnosis of infection with N. gonorrhoeae can be performed by testing endocervical, vaginal, urethral (men only), or urine specimens. Culture, nucleic acid hybridization tests, and NAATs are available for the detection of genitourinary infection with N. gonorrhoeae.  Culture and nucleic acid hybridization tests require female endocervical or male urethral swab specimens.
  32. 32. • NAATs allow testing of the widest variety of specimen types including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women), and they are FDAcleared for use . •The sensitivity of NAATs for the detection of N. gonorrhoeae in genital and nongenital anatomic sites is superior to culture but varies by NAAT type.
  33. 33. Gram Stain for GC: Urethral Smear   Numerous PMNs Gram negative intracellular diplococci
  34. 34. Gram Stain for GC: Cervical Smear  PMN with Gram negative intracellular diplococci
  35. 35. GC Culture     Requires selective media with antibiotics to inhibit competing bacteria (Modified Thayer Martin Media, NYC Medium) Sensitive to oxygen and cold temperature Requires prompt placement in high-CO2 environment (candle jar, bag and pill, CO2 incubator) In cases of suspected sexual abuse, culture is the only test accepted for legal purposes
  36. 36. GC Culture Candle Jar
  37. 37. GC Culture Specimen Streaking Cervical and Urethral
  38. 38. GC Culture After 24 Hours
  39. 39. Management  It is important to receive treatment for gonorrhoea quickly.  Patients with gonorrhea frequently also have chlamydia, they are treated for both diseases  In recent years, drug resistant gonorrhea has become more problematic, both in the United States and worldwide  In the summer of 2012, the CDC updated the guidelines again - recommending that all gonorrhea cases be treated with injectable, rather than oral, antibiotics.
  40. 40.  Treatment depends on the site of involvement. Infections that have spread beyond the primary site of infection like DGI,pelvic inflammatpory diseses or epididymitis, may also require more intense treatment.  When you are being treated for gonorrhea it is important that your sexual partners are treated as well.  People who are infected with gonorrhea once are likely to become infected again, so 3 months later for a check up is necesssary.
  41. 41.  Single-dose cephalosporin regimens (Both sex partners) Inj.Ceftriaxon (Ceftron) I/V or I/M or – Inj Spectinomycin 2 g in a single IM dose
  42. 42.  Fluoroquinolones are no longer recommended for therapy for gonorrhea acquired in Asia, the Pacific Islands (including Hawaii), and California.
  43. 43. Pregnant women should not be treated with quinolones .Treat with alternate cephalosporin  If cephalosporin is not tolerated, treat with spectinomycin 2 g IM once 
  44. 44. Co-treatment for Chlamydia  If chlamydial infection is not ruled out: Tab.Azithromycin 1 gm (Tab.Zimax-500mg) Orally Once or Doxycycline (Cap.Doxacil-100 mg) Orally Twice a day for 7 days
  45. 45. DGI Treatment Initial IV Therapy Begin IV therapy for 24-48 hrs, switch to oral therapy for a total of 1 week Recommended regimen: – Ceftriaxone 1g IV or IM q 24 h Alternative Regimens: – – – – – – Cefotaxime 1 g IV q 8 h Ceftizoxime 1 g IV q 8 h Ciprofloxacin 400 mg IV q 12 h Ofloxacin 400 mg IV q 12 h Levofloxacin 250 mg IV q 24 h Spectinomycin 2 g IM q 12 h
  46. 46. DGI Treatment Subsequent Oral Therapy Oral therapy for total treatment of 1 week: Recommended Regimes: – Cefixime 400 mg PO BID – Ciprofloxacin 500 mg PO BID – Ofloxacin 400 mg PO BID – Levofloxacin 500 mg PO QD
  47. 47. Follow-Up   A test of cure is not recommended if a recommended regimen is administered. If symptoms persist, perform culture for N. gonorrhoeae. – Any gonococci isolated should be tested for antimicrobial susceptibility.
  48. 48. Prevention strategies:       Health promotion, education & counseling Increased access to condoms Early detection through screening in selected high risk populations Effective diagnosis & treatment Partner management Risk reduction counseling
  49. 49. Home messages: – Gonorrhoea is usually symptomatic in males and asymptomatic in females – Untreated infections can result in PID, infertility, and ectopic pregnancy in women and epididymitis and stricture urethra in men
  50. 50.      It can be acquired from asymptomatic partner. Both sex partners need to be treated at a time. Over diagnosis of gonorrhoea should be avoided Mainly transmited by sexual contact. Rarely children may be affected as result of sexual abuse.
  51. 51.  All persons found to have who have gonorrhea also should be tested for other STDs, including chlamydia, syphilis, and HIV.  A growing number of cases are being reported globally of an antibiotic-resistant strain known as HO41  Safe sex practice and sex with legal partners can prevent gonorrhoea in our society
  52. 52. Acknowledgements       Prof. Hasibur Rahman Dr.Hadiuzzaman Dr.Nahida Islam Nipa Dr.Sabrina Alam Mumu Dr. Atia Afrose Jecy. Square Pharmaceuticals Limited
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