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Gonorrhoea Update
 

Gonorrhoea Update

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    Gonorrhoea Update Gonorrhoea Update Presentation Transcript

    • 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
    • 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
    • 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
    • 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
    • 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
    • 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 )
    •   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
    • Microbiology  Etiologic agent: Neisseria gonorrhoeae  Gram-negative intracellular diplococcus  Infects mucus-secreting epithelial cells
    • 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 – Discharge may be clear or cloudy   Asymptomatic in 10% of cases Incubation period: usually 1-14 days for symptomatic disease, but may be longer
    • Gonococcal Urethritis: Purulent Discharge
    • Epididymitis    Symptoms: unilateral testicular pain and swelling Infrequent, but most common local complication in males Usually associated with overt or subclinical urethritis
    • Swollen or Tender Testicles (Epididymitis)
    • LOCAL        COMPLICATIONS in Male Urethral stricture Periurethral abscess Prostatitis Prostatic abscess Seminal vasiculitis Epidedymitis Orchitis
    • Genital Infection in Women  Most infections are asymptomatic  Cervicitis – inflammation of the cervix  Urethritis – inflammation of the urethra
    • 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
    • Gonococcal Cervicitis
    • Urethritis  Symptoms: dysuria, however, most women are asymptomatic  40%-60% of women with cervical gonococcal infection may have urethral infection
    • 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:  Gestational bleeding  Preterm labor and delivery  Premature rupture of membranes
    • Gonorrhea Infection in Children  Perinatal: infections of the conjunctiva, pharynx, respiratory tract  Older children (>1 year): considered possible evidence of sexual abuse
    • 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 arthritis Perihepatitis Gonococcal Dermatitis
    • Disseminated Gonorrhea— Skin Lesion
    • 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 
    • 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
    • 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
    •  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.
    • • 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.
    • 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 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
    • 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 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.
    •  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.
    •  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
    •  Fluoroquinolones are no longer recommended for therapy for gonorrhea acquired in Asia, the Pacific Islands (including Hawaii), and California.
    • Pregnant women should not be treated with quinolones .Treat with alternate cephalosporin  If cephalosporin is not tolerated, treat with spectinomycin 2 g IM once 
    • 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
    • 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
    • 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
    • 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.
    • 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
    • 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
    •      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.
    •  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
    • Acknowledgements       Prof. Hasibur Rahman Dr.Hadiuzzaman Dr.Nahida Islam Nipa Dr.Sabrina Alam Mumu Dr. Atia Afrose Jecy. Square Pharmaceuticals Limited