Gonococcal infections

Gonococcal Infections in HIV-Infected Persons The association between gonorrhea and the acquisition of HIV has been demonstrated in several well-controlled studies, mainly in Kenya and Zaire. The nonulcerative STIs enhance the transmission of HIV by three- to fivefold, possibly because of increased viral shedding by persons with urethritis or cervicitis (Chap. 182). HIV has been detected by polymerase chain reaction (PCR) more commonly in ejaculates from HIV-positive men with gonococcal urethritis than in those from HIV-positive men with nongonococcal urethritis.

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Gonococcal Infections: Treatment Treatment failure can lead to continued transmission and the emergence of antibiotic resistance. The importance of adequate treatment with a regimen that the patient will adhere to cannot be overemphasized. Thus highly effective single-dose regimens have been developed for uncomplicated gonococcal infections.

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The clinical manifestations of DGI have sometimes been classified into two stages: a bacteremic stage, which is less common today, and a joint-localized stage with suppurative arthritis. A clear-cut progression usually is not evident. Patients in the bacteremic stage have higher temperatures, and their fever is more frequently accompanied by chills. Painful joints are common and often occur in conjunction with tenosynovitis and skin lesions. Polyarthralgias usually include the knees, elbows, and more distal joints; the axial skeleton is generally spared.

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Single-dose regimens of the third-generation cephalosporins ceftriaxone (given IM) and cefixime (given orally) are the mainstays of therapy for uncomplicated gonococcal infection of the urethra, cervix, rectum, or pharynx. Quinolone-containing regimens are no longer recommended in the United States as first-line treatment because of widespread resistance to these agents. Because co-infection with C. trachomatis occurs frequently, initial treatment regimens must also incorporate an agent (e.g., azithromycin or doxycycline) that is effective against chlamydial infection.

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Gonococcal Resistance to Antimicrobial Agents It is no surprise that N. gonorrhoeae, with its remarkable capacity to alter its antigenic structure and adapt to changes in the microenvironment, has become resistant to numerous antibiotics. The first effective agents against gonorrhea were the sulfonamides, which were introduced in the 1930s and became ineffective within a decade. Penicillin was then employed as the drug of choice for the treatment of gonorrhea. By 1965, 42% of gonococcal isolates had developed lowlevel resistance to penicillin G.

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Gonococcal Infections in Females Gonococcal Cervicitis Mucopurulent cervicitis is the most common STI diagnosis in American women and may be caused by N. gonorrhoeae, C. trachomatis, and other organisms. Cervicitis may coexist with candidal or trichomonal vaginitis. N. gonorrhoeae primarily infects the columnar epithelium of the cervical os. Bartholin's glands occasionally become infected. Women infected with N. gonorrhoeae usually develop symptoms. However, the women who either remain asymptomatic or have only minor symptoms may delay in seeking medical attention.

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Opacity-Associated Protein Another gonococcal surface protein that is important in adherence to epithelial cells is opacity-associated protein (Opa, formerly called protein II). Opa contributes to intergonococcal adhesion, which is responsible for the opaque nature of gonococcal colonies on translucent agar and the organism's adherence to a variety of eukaryotic cells, including polymorphonuclear leukocytes (PMNs).

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Ocular Gonorrhea in Adults Ocular gonorrhea in an adult usually results from autoinoculation from an infected genital site. As in genital infection, the manifestations range from severe to occasionally mild or asymptomatic disease. The variability in clinical manifestations may be attributable to differences in the ability of the infecting strain to elicit an inflammatory response. Infection may result in a markedly swollen eyelid, severe hyperemia and chemosis, and a profuse purulent discharge. The massively inflamed conjunctiva may be draped over the cornea and limbus.

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Harrison's Internal Medicine Chapter 137. Gonococcal Infections Definition Gonorrhea is a sexually transmitted infection (STI) of epithelium and commonly manifests as cervicitis, urethritis, proctitis, and conjunctivitis. If untreated, infections at these sites can lead to local complications such as endometritis, salpingitis, tuboovarian abscess, bartholinitis, peritonitis, and perihepatitis in female patients; periurethritis and epididymitis in male patients; and ophthalmia neonatorum in newborns.

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