This document summarizes information about Neisseria gonorrhoeae (GC) and gonorrhea. It discusses that gonorrhea is the most common bacterial sexually transmitted disease. GC can cause a range of clinical syndromes by infecting mucosal surfaces. Transmission occurs through sexual contact and GC has developed increasing antibiotic resistance over time. Diagnosis and treatment recommendations are provided.

2. Most common bacterial STD.
Incidence highest among adolescents and young
adults.
Causes a range of clinical syndromes

3.  Adolescents > age 20-25 years > older
 Black/Hispanic > White/API
 Multiple sex partners
 Inconsistent use of barrier methods

4. Can be acquired from asymptomatic partner
It is greater from male to female
Male to female: 50 - 90%
Female to male: 20 - 80%
Vaginal & anal intercourse more efficient than oral
Increases transmission and susceptibility to HIV 2-5
fold
Efficiently transmitted by sexual contact

6. Observed intracellularly in PMNs on Gram stain
Gram-negative diploccocus
Infects non-cornified epithelium
Cervix, Urethra , Rectum , Pharynx , Conjunctiva

7. GC are ingested,
evade host defenses,
and spread through
subepithelial tissues
Attachment mediated
by pili and divides
every 20-30 min.
Leads to formation of submucosal
abscesses
and accumulation of exudate in lumen
GC toxins damage
cells

8.  Cervicitis
 Urethritis
 Proctitis
 Accessory gland infection (Skene, Bartholin)
 Pelvic inflammatory disease (PID)
 Peri-hepatitis (Fitz-Hugh-Curtis)
 Pregnancy morbidity
 Conjunctivitis
 Pharyngitis
 DGI

9. Complications of GC Infections
in Women
Congenital Infection
Upper Tract
Infection
Genital
Infectio
n
 Infertility
 Ectopic Pregnancy
 Chronic Pelvic Pain
 Psychosocial
HIV Infection
Local Invasion
Systemic Infection

10. Incubation 3-10 days
Symptoms:
Vaginal discharge
Dysuria
Vaginal bleeding
Cervical signs :
Erythema
Friability
Purulent exudate

11.  Tender swollen
Bartholin’s gland
with purulent
discharge.

12.  Painful swollen Bartholin’s
glands
 Fluctuant, tender
 May have expressible
purulent discharge

13.  Sx: lower abdominal painAdhesions
Tube
 Laparoscopy may show
hydrosalpinx,
inflammation, abscess,
adhesions
 Signs: uterine/ adnexal
tenderness, +/- fever

14.  Urethritis
 Epididymitis
 Proctitis
 Conjunctivitis
 Abscess of Cowper’s/Tyson’s glands
 Seminal vesiculitis
 Prostatitis
 Pharyngitis
 DGI
 Urethral stricture
 Penile edema

15.  Incubation 2-7 days
 Most urethral infections
symptomatic
 Purulent urethral discharge
 Abrupt onset of severe dysuria

16.  Swollen painful epididymis
 Urethritis
 Epididymal tenderness or mass
on exam
Epididymitis

17.  Urethritis
 Proctitis
 Pharyngeal infections
 Conjunctivitis
 Disseminated
Gonococcal Infection

18.  Marked chemosis
and tearing
 Typically purulent
discharge,
 Erythema

19.  Conjunctival erythema and discharge

20.  Gonococcal bacteremia
 Patients with congenital deficiency of C7, C8, C9 are
at high risk
 More common in females
 Occurs in < 5% of GC-infected patients
 Sources of infection include symptomatic and
asymptomatic infections of pharynx, urethra, cervix

21.  “Dermatitis-arthritis syndrome”
Arthritis: 90%
Characterized by fever, chills, skin lesions,
arthralgias, tenosynovitis
Less commonly, hepatitis, myocarditis,
endocarditis, meningitis
 Rash characterized as macular or papular, pustular,
hemorrhagic or necrotic, mostly on distal extremities

22.  Necrotic, grayish
central lesion on
erythematous base

23.  Papular and pustular
lesions on the foot

24.  Small painful midpalmar
lesion on an erythematous
base

25.  Pustular erythematous
lesions

26.  Papular erythematous
skin lesion

27.  Meningococcemia
 Staphylococcal sepsis or endocarditis
 Other bacterial septicemias
 Acute HIV infection
 Thrombocytopenia & arthritis
 Hepatitis B prodrome
 Reiter’s Syndrome
 Juvenile Rheumatoid Arthritis
 Lyme disease

28.  Postpartum endometritis
 Septic abortions
 Post-abortal PID
Possible role in:
Gestational bleeding
Preterm labor and delivery
Premature rupture of membranes

29. Overall vertical transmission rate ~30%
Neonatal complications include:
Ophthalmia neonatorum
Disseminated gonococcal infection (sepsis, arthritis,
meningitis)
Scalp abscess (if fetal scalp monitor used)
Vaginal and rectal infections
Pharyngeal infections

30.  Lid edema, erythema
and marked purulent
discharge
 Preventable with
ophthalmic ointment

31. Culture should be obtained
All cases should be considered possible
evidence of sexual abuse
 Vulvovaginits
 Urethritis
 Proctitis

32.  Gram stain smear
 Culture
 Antigen Detection Tests.
 Nucleic Acid Detection Tests
◦ Probe Hybridization
◦ Nucleic Acid Amplification Tests (NAATs)
◦ Hybrid Capture

33. Gram stain
(male urethra exudate)
DNA probe
Culture
NAATs *
Sensitivity
90-95%
85-90%
80-95%
90-95%
Specificity
> 95%
> 95%
> 99%
> 98%
* Able to use URINE specimens

34. Accessory gland infection: similar to male urethritis
Not useful in pharyngeal infections
In cervicitis & Proctitis :
50-70%sensitivity, 95% specificity
In symptomatic male urethritis:
>95% sensitivity and specificity: reliable to diagnose and exclude GC

35.  Numerous PMNs
 Gram negative
intracellular
diplococci

36.  PMN with Gram
negative
intracellular
diplococci

37. In cases of suspected sexual abuse, culture is the only
test accepted for legal purposes
Requires prompt placement in high-CO2environment
(candle jar, CO2 incubator)
Sensitive to oxygen and cold temperature
Requires selective media with antibiotics to inhibit
competing bacteria (Modified Thayer Martin Media, NYC
Medium)

41. Recommended regimens:
Cefixime 400 mg PO x 1 or
Ceftriaxone 125 mg IM x 1 or
Ciprofloxicin 500 mg PO x 1 or
Ofloxacin 400 mg PO x 1 or
Levofloxacin 500 mg PO x 1
All sex partners within past 60 days need evaluation and
treatment
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1 or
Doxycycline 100 mg PO BID x 7 d

42. Alternative regimens:
 Ceftizoxime 500 mg IM x 1
 Cefotaxime 500 mg IM x 1
 Cefoxitin 2 g IM x 1 + probenecid 1 g PO x 1
 Gatifloxacin 400 mg PO x 1
 Lomefloxacin 400 mg PO x 1
 Norfloxacin 800 mg PO x 1
 Spectinomycin 2 g IM x 1

43. Pharyngeal infection:
Ceftriaxone 125 mg IM x 1 or
Ciprofloxicin 500 mg PO x 1 or
Conjunctivitis:
Ceftriaxone 1 g IM x 1 dose
PLUS if chlamydia is not ruled out:
Azithromycin 1 g PO x 1 or
Doxycycline 100 mg PO BID x 7 d

44. Must avoid quinolones & tetracycline
Recommended regimens:
 Cefixime 400 mg PO x 1
 Ceftriaxone 125 mg IM x 1
PLUS if chlamydia is not ruled out:
 Azithromycin 1 g PO x 1 
 Other appropriate chlamydial regimen
Test of cure in 3-4 weeks

45. Ophthalmia neonatorum prophylaxis:
Silver nitrate 1% aqueous solution topical x 1
Erythromycin 0.5% ointment topical x 1
Tetracycline 1% ointment topical x 1
Ophthalmia neonatorum treatment:
Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125
mg

46. Prophylaxis for maternal GC infection:
Ceftriaxone 25-50 mg/kg IV or IM x 1 NTE 125 mg
Disseminated Gonococcal Infection:
Ceftriaxone 25-50 mg/kg/d IV or IM QD x 7 d
(use 50 mg/kg/d for older children,
treat for 10-14 d if child weighs ≥ 45 kg)
Cefotaxime 25 mg/kg IV or IM q12h x 7 d

47. Uncomplicated genital infection:
◦ ≥ 45 kg: same as adults
◦ < 45 kg: ceftriaxone 125 mg IM x 1 (alternative
spectinomycin 40 mg/kg IM x 1)
Disseminated Gonococcal Infection:
Ceftriaxone 25-50 mg/kg/d x 7 d
Use 50 mg/kg/d for older children
Treat for 10-14d if child weighs ≥ 45 kg

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

49. Recommended Regimes:
◦ Cefixime 400 mg PO BID
◦ Ciprofloxacin 500 mg PO BID
◦ Ofloxacin 400 mg PO BID
Oral therapy for total treatment of 1 week

50.  Resistance in 20%-30% of gonococcal isolates
 Plasmid mediated
◦ B - Lactamase production
◦ High-level tetracycline resistance
 Chromosomal mediated
◦ Confers resistance to PCN, tetracycline, spectinomycin,
erythromycin, fluoroquinolones, and/or cephalosphorins