Neisseria gonorrhoeae infection: Clinical sciences

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Introduction0:00–0:50

Neisseria gonorrhoeae is the second most common sexually transmitted bacterial infection in the United States, and it’s a mandatory reportable infection as a public health measure.
It can affect multiple anatomic sites, most commonly the urethra and cervix, but also the eyes, oropharynx, and rectum. Many infections are asymptomatic.
Now, untreated infections can result in pelvic inflammatory disease, which increases the patient’s risk for ectopic pregnancy, infertility, and chronic pelvic pain.
Transmission of gonorrhea to the neonate can occur during vaginal delivery. Gonorrhea in neonates can lead to infections such as ophthalmia neonatorum, also called gonococcal conjunctivitis, which may lead to blindness.
Your first step in evaluating a patient who presents with a chief concern suggesting Neisseria gonorrhoeae infection is a focused history and physical exam.

Biologically male0:50–3:32

Let’s begin with biologically male patients. First, obtain a complete sexual history including questions about new partners and both oral and anal intercourse.
Be sure to discuss sexual activity, particularly recent sexual activity or new partners. Provide a private, confidential discussion.
Although it may be difficult, you should ask caregivers of young patients to step out of the room for this discussion. Additionally, always consider sexual assault or abuse whenever a young patient has a positive sexual activity history, especially if the patient is a child.
If there is abuse going on, you will need to follow up with allegations of abuse in accordance with your State’s law.Now patients may report a variety of symptoms, corresponding to the site of infection.
They may describe a sore, itchy throat and difficulty swallowing or pelvic symptoms such as pelvic pain, dysuria, thick greenish or yellow urethral discharge, or testicular pain or swelling.
Lastly, they might report rectal symptoms including painful bowel movements or rectal spotting. On a physical exam, your findings will reflect the site of infection.
Signs of conjunctivitis include erythema of the conjunctiva, swelling of the eyelid, or purulent ocular discharge. With pharyngitis, you might find an erythematous throat and cervical lymphadenopathy.
Urethritis may present with purulent urethral discharge. In the case of epididymitis, you might find unilateral swelling and tenderness of a testicle as well as abdominal tenderness.
Next, prostatitis typically presents with a firm, tender, and edematous prostate on a digital rectal exam. Lastly, proctitis may present with swollen, tender, and erythematous rectal mucosa.Here is a high-yield fact!
Disseminated gonococcal infections are unusual but clinically significant. These patients may present with a rash on the hands and feet, arthralgias, tenosynovitis, or septic arthritis, and they may develop endocarditis and meningitis.
Additionally, biological females may have pelvic inflammatory disease and perihepatitis. Treatment includes hospitalization, appropriate antibiotics, and consultation with an infectious disease specialist.
Now back to the patient. If you suspect Neisseria gonorrhoeae infection, your next step is to perform laboratory testing for gonorrhea.

Biologically male - Diagnostic testing3:32–4:52

Your history and physical exam will guide your testing sites. A nucleic acid amplification test, or NAAT, can be performed by swabbing the appropriate site, which may include the eye, throat, urethra, or rectum.
A first-void urine collection can also be sent for NAAT testing to diagnose urogenital infections. Alternatively, a gonorrhea culture can be performed by swabbing the site of the suspected infection.
Although historically culture was used for diagnosis, culture is rarely performed today. Finally, a gram stain of urethral discharge can be obtained if the patient has signs of urethritis.Time for another high-yield fact!
In biologically male patients, a positive gram stain of urethral discharge is highly specific and sensitive for diagnosing symptomatic gonococcal urethritis.
A positive stain will demonstrate polymorphonuclear leukocytes with intracellular gram-negative diplococci. This test is not useful for screening for gonococcal infections of the throat or rectum.
Also, be aware that in asymptomatic patients, a negative gram stain does not rule out infection.Alright, now that we ordered tests, let’s talk about the results.
If NAAT or culture are negative, consider an alternative diagnosis. However, if the NAAT, culture, or gram stain is positive, you have made your diagnosis of Neisseria gonorrhoeae infection.

Biologically male - Management4:52–7:18

Treat patients with an antibiotic, such as intramuscular ceftriaxone. Also, keep in mind that chlamydia coinfection is quite common; so if chlamydia infection has not been excluded, you should treat for chlamydia as well by adding an oral antibiotic like doxycycline or azithromycin.
To ensure compliance, treat patients on-site or refer to an STI clinic for same-day treatment. After administering antibiotics to your patient, be sure to refer all sexual partners for evaluation and treatment as well.
If partners cannot access services for evaluation and treatment, consider expedited partner therapy, or EPT, which allows you to treat their sexual partners without requiring them to come in for an examination.
In addition, counsel patients to abstain from intercourse until 7 days following completion of treatment, and until symptoms have resolved and all partners are treated.
Since patients with one STI are at high risk for another, perform additional STI testing to screen for chlamydia, syphilis, and HIV.
You should offer HIV pre-exposure prophylaxis, or PrEP, to patients who are HIV-negative because it reduces the risk of acquiring HIV.
Finally, in cases of pharyngitis, perform a test of cure in 7 to 14 days. If tests remain positive or symptoms persist, be sure to obtain cultures with sensitivities.
Pharyngitis is harder to eradicate than urogenital or rectal gonorrhea and is a large source of community transmission. Retest all patients, regardless of infection site, at 12 weeks after treatment, as there is a high prevalence of gonorrhea among patients with previous infections.
Here is a clinical pearl to keep in mind! Treatment of gonorrhea has been complicated by antimicrobial resistance.
If treatment with a cephalosporin fails and you suspect antibiotic resistance, but not reinfection, you’ll need to send a gonorrhea culture with sensitivities and report this to your local and state public health authorities.Now that biologically male patients are taken care of, let’s talk about biologically female patients.
As before, begin with a complete and confidential sexual history. Now, physical symptoms may include a sore and itchy throat or difficulty swallowing, pelvic pain, thick greenish or yellow vaginal discharge, vaginal pruritus, and vaginal spotting.On the physical, you could find evidence of conjunctivitis, pharyngitis, and cervical lymphadenopathy; lower abdominal and pelvic tenderness; and signs of urethritis.

Biologically female7:18–8:27

In addition, signs of cervicitis may be present which could include an edematous, friable cervix and mucopurulent cervical discharge.
Here is a high-yield fact: The majority of gonococcal infections are asymptomatic, particularly in biologically female patients, and annual screening is recommended among high-risk populations, including women under the age of 25 and men who have sex with men.Now, if you suspect Neisseria gonorrhoeae infection, the very first step in a biologically female patient is to get an HCG pregnancy test; followed by NAAT or, rarely, gonorrhea culture.
As before, the specimen can be collected at the eye, throat, urethra, cervix, vagina, or rectum. First-void urine can be collected for NAAT testing as well.

Biologically female - Diagnostic testing8:27–9:13

However, keep in mind that the most accurate approach is either patient self-collected or provider collected swab of the infected area.
If the testing is negative, consider an alternative diagnosis. On the other hand, if the NAAT or gonorrhea culture is positive, you have your diagnosis of Neisseria gonorrhoeae infection.
Next, assess for pregnancy with the HCG test you obtained previously. This is important because you might need to choose different antibiotics.
If the patient has a negative HCG pregnancy test, the preferred treatment is intramuscular ceftriaxone administered at the time of diagnosis.
If chlamydia infection has not been excluded, you should treat for chlamydia as well by adding an oral antibiotic like doxycycline or azithromycin.

Biologically female - Management9:13–11:59

Again, refer all partners for treatment and consider EPT. Counsel patients to abstain from intercourse for 7 days after treatment, until symptoms are resolved, and all partners are treated.
Perform additional STI testing to screen for HIV, chlamydia, and syphilis, and offer HIV PreP to patients who screen negative for HIV.
Perform a test of cure in 7 to 14 days for patients with pharyngitis, and consider a culture with sensitivities if the testing remains positive or pharyngeal symptoms persist.
Finally, repeat gonorrhea testing at 12 weeks due to their risk of reinfection.Here’s a clinical pearl! If a patient with Neisseria gonorrhoeae infection has an intrauterine device, or IUD, in place, the IUD doesn’t need to be removed as part of the management plan.
However, patients with current purulent cervicitis or gonorrhea infection who don’t have an IUD in place should not undergo IUD insertion until being treated first.Now, let’s go back and assess for pregnancy once again.
If the patient has a positive HCG pregnancy test, you should still administer intramuscular ceftriaxone, as it is safe to use during pregnancy.
If chlamydia infection has not been excluded, you should treat for chlamydia as well by adding an oral antibiotic that’s safe in pregnancy, such as azithromycin, but be sure to avoid doxycycline!
Once again, refer partners for treatment; counsel patients to abstain from intercourse; perform additional STI testing to screen for HIV, chlamydia, and syphilis, and possibly offer PrEP if clinically appropriate.
Don’t forget the test of cure at 7 to 14 days for pharyngitis. In addition, you should repeat gonorrhea testing at 12 weeks and again in the third trimester to prevent neonatal infections including ophthalmia neonatorum and neonatal sepsis.Here’s another high-yield fact!
Even though prenatal screening for gonorrhea is recommended during pregnancy, it is sometimes missed, and so most states encourage neonatal ocular prophylaxis with erythromycin ophthalmic ointment, which is safe, inexpensive, and easy to administer.Alright, as a quick recap… Neisseria gonorrhoeae can affect multiple anatomic sites, most commonly the urethra and cervix, causing thick greenish or yellow discharge; but can also affect the eyes, oropharynx, and rectum.
When patients present with symptoms of gonorrhea, testing can be done with NAAT or, rarely, gonorrhea culture. Treatment involves antibiotics like intramuscular ceftriaxone.
Additionally, if chlamydia infection hasn’t been excluded, you should add an oral antibiotic like doxycycline or azithromycin.

Review11:59–12:53

Next, you should discuss treatment for their partner, and counsel on abstinence following treatment. Additional STI testing should be performed, and if they have gonococcal pharyngitis, be sure to perform a test of cure at 7 to 14 days.
Lastly, retest all patients 12 weeks after initial treatment and, in pregnant patients, repeat the test in the third trimester to help prevent neonatal infections.
and counsel an abstinence following treatment Additional sti testing should be performed and if they have gonococcal pharyngitis be sure to perform a test of cure at 7 to 14 days Lastly retest all patients 12 weeks after initial treatment and in pregnant patients repeat the test in the third