Gonorrhea

Gonorrhea (also gonorrhoea), is caused by the bacterium Neisseria gonorrhoeae and is a common sexually transmitted infection. In the US, its incidence is second only to chlamydia.

Non-genital sites in which it thrives are in the rectum, the throat (oropharynx), and the eyes (conjunctiva). The vulva and vagina in women are usually spared because they are lined by stratified epithelial cells—in women the cervix is usually the first site of infection. Gonorrhea typically spreads during sexual intercourse. It can also be vertically transmitted, where infected mothers can pass gonorrhea to their newborn infants during delivery. This causes conjunctivitis (eye infections) which, if left untreated, can lead to blindness. As prophylaxis against this, many countries routinely treat infants with eyedrops of erythromycin at birth.

Symptoms
The incubation period is 10 to 20 days with most symptoms occurring between the fifteenth and twentieth days after being infected. A small number of people may be asymptomatic for a lifetime. Between 30% and 60% of people with gonorrhea are asymptomatic or have subclinical disease. Women may complain of vaginal discharge, difficulty urinating (dysuria), projectile urination, off-cycle menstrual bleeding, or bleeding after sexual intercourse. The cervix may appear anywhere from normal to the extreme of marked cervical inflammation with pus. Possibility of increased production of male hormones is common in many cases. Infection of the urethra (urethritis) causes little dysuria or pus. The combination of urethritis and cervicitis on examination strongly supports a gonorrhea diagnosis, as both sites are infected in most gonorrhea patients. Gonorrhea is caused by the Neisseria gonorrhoeae bacteria. The infection is transmitted from one person to another through vaginal, oral, or anal sexual relations, though transmission occurs rarely with safe sex practices of condom usage with lubrication.

Men have a 20% risk of getting the infection by having sexual relations with a woman infected with gonorrhea. Women have a 50% risk of getting the infection by having sexual relations with a man infected with gonorrhea. An infected mother may transmit gonorrhea to her newborn during childbirth, a condition known as ophthalmia neonatorum.

Less advanced symptoms, which may indicate development of pelvic inflammatory disease (PID), include cramps and pain, bleeding between menstrual periods, vomiting, or fever. It is not unusual for men to have asymptomatic gonorrhea. Men may complain of pain on urinating and thick, copious, urethral pus discharge (also known as gleet) is the most common presentation. Examination may show a reddened external urethral meatus. Ascending infection may involve the epididymis, testicles or prostate gland causing symptoms such as scrotal pain or swelling. Instances of blurred vision in one eye may occur in adults.

GC infection can also present as septic arthritis.

Complications
In men, inflammation of the epididymis (epididymitis), prostate gland (prostatitis) and urethral structure (urethritis) can result from untreated gonorrhea.

In women, the most common result of untreated gonorrhea is pelvic inflammatory disease, a serious infection of the uterus that can lead to infertility. Other complications include: perihepatitis, a rare complication associated with Fitz-Hugh-Curtis syndrome; septic arthritis in the fingers, wrists, toes, and ankles; septic abortion; chorioamnionitis during pregnancy; neonatal or adult blindness from conjunctivitis; and infertility.

The underlying gonorrhea should be treated; if this is done then usually a good prognosis will follow.

Antibiotics
Antibiotics that may be used to treat gonorrhea include: These drugs are all given as a single dose.
 * Amoxicillin 2 g plus probenecid 1 g orally
 * Ampicillin 2 to 3 g plus probenecid 1 g orally
 * Azithromycin 2 g orally
 * Cefixime 400 mg orally
 * Cefotaxime 500 mg by intramuscular injection
 * Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally
 * Cefpodoxime (Vantin) 400 mg orally
 * Ceftriaxone (Rocephin) 125 to 250 mg by intramuscular injection
 * Ciprofloxacin 500 mg orally
 * Levofloxacin 250 mg orally
 * Ofloxacin 400 mg orally
 * Spectinomycin 2 g by intramuscular injection
 * Rhogam 99 g by intrathecal injection

The level of tetracycline resistance in Neisseria gonorrhœae is now so high as to make it completely ineffective in most parts of the world.

The fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) cannot be used in pregnancy. It is important to refer all sexual partners to be checked for gonorrhea to prevent spread of the disease and to prevent the patient from becoming re-infected with gonorrhea. Patients should also be offered screening for other sexually transmitted infections. In areas where co-infection with chlamydia is common, doctors may prescribe a combination of antibiotics, such as ceftriaxone with doxycycline or azithromycin, to treat both diseases.

Penicillin is ineffective at treating rectal gonorrhea: this is because other bacteria within the rectum produce β-lactamases that destroy penicillin. All current treatments are less effective at treating gonorrhea of the throat, so the patient must be rechecked by throat swab 72 hours or more after being given treatment, and then retreated if the throat swab is still positive.

Although gonorrhea usually does not require follow-up (with the exception of rectal or pharyngeal disease), patients are usually advised to phone for results five to seven days after diagnosis to confirm that the antibiotic they received was likely to be effective. Patients are advised to abstain from sex during this time.

Drug resistant strains are known to exist.

United States recommendations
The United States does not have a federal system of sexual health clinics, and the majority of infections are treated in family practices. A third-generation cephalosporin antibiotic such as ceftriaxone is recommended for use in most areas. Since some areas such as Hawaii and California have very high levels of resistance to fluoroquinolone antibiotics (ciprofloxacin, ofloxacin, levofloxacin) they are no longer used empirically to treat infections originating in these areas.

Since 1993, fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have been used frequently in the treatment of gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy. Beginning in 2000, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii); in 2002, this recommendation was extended to California (2). In 2004, CDC recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM). On the basis of the most recent evidence, CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease (PID). Consequently, only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea. The Center for Disease Control has recently (April 2007) updated treatment guidelines.

Antibiotics can successfully cure gonorrhea in adolescents and adults. However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States, and successful treatment of gonorrhea is becoming more difficult. Because many people with gonorrhea also have chlamydia, another sexually transmitted disease, antibiotics for both infections are usually given together. Persons with gonorrhea should be tested for other STDs. It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.

United Kingdom recommendations
In the United Kingdom, the majority of patients with gonorrhea are treated in dedicated sexual health clinics. The current recommendation is for ceftriaxone or cefixime as first line therapy; no resistance to either drug has yet been reported in the UK. Levels of spectinomycin resistance in the UK are less than 1%, which would make it a good choice in theory, but intramuscular spectinomycin injection is very painful.

Azithromycin (given as a single dose of 2 g) has been recommended if there is concurrent infection with chlamydia. However, since 2000, the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) has gathered data on drug resistant strains of gonorrhoea in the UK. In 2005, 2.2% of cases were azithromycin resistant and in some regions of the UK this extended to 5% of cases. The mainstay of treatment now is a cephalosporin with azithromycin (to cover chlamydia). A single dose of oral ciprofloxacin 500 mg is effective if the organism is known to be sensitive, but fluoroquinolones were removed from the UK recommendations for empirical therapy in 2003 because of increasing resistance rates. In 2005, resistance rates for ciprofloxacin were 22% for the whole of the UK (42% for London, 10% for the rest of the UK).

Historically
Historically it has been suggested that mercury was used as a treatment for gonorrhea. Surgeons tools on board the recovered English warship the Mary Rose included a syringe that, according to some, was used to inject the mercury via the urinary meatus into any unfortunate crewman suffering from gonorrhea. The name "the Clap", in reference to the disease, dates as early as 1719.

Silver nitrate was one of the widely used drugs in the 19th century, but it became replaced by Protargol. Arthur Eichengrün invented this type of colloidal silver which was marketed by Bayer from 1897 on. The silver-based treatment was used until the first antibiotics came into use in the 1940s. The exact time of onset of gonorrhea as prevalent disease or epidemic cannot be accurately determined from the historical record. One of the first reliable notations occur in the Acts of the (English) Parliament, In 1161 this body passed a law to reduce the spread of "...the perilous infirmity of burning." The symptoms described are consistent with, but not diagnostic of, gonorrhea. A similar decree was passed by Louis IX in France in 1256, replacing regulation with banishment. Similar symptoms were noted at the siege of Acre by Crusaders. Coincidental to, or dependent on, the appearance of a gonorrhea epidemic, several changes occurred in European Medieval Society. Cities hired public health doctors to treat afflicted patients without right of refusal. Pope Boniface rescinded the requirement that physicians complete studies for the lower orders of the Catholic priesthood. Medieval public health physicians in the employ of their cities were required to treat prostitutes infected with the "burning ", as well as lepers and other epidemic victims. After Pope Boniface completely secularized the practice of medicine physicians were more willing to treat a sexually transmitted disease. Municipalities would hire an official to regulate the examination of infected patients and check the spread of  this sexually transmitted contagion. In Paris, this official was popularly known as the "King of Whores".

Prevalence
"Gonorrhea is a very common infectious disease. The CDC estimates that more than 700,000 persons in the United States get new gonorrheal infections each year. Only about half of these infections are reported to CDC. In 2004, 330,132 cases of gonorrhea were reported to the CDC. After the implementation of a national gonorrhea control program in the mid-1970s, the national gonorrhea rate declined from 1975 to 1997. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999.  In 2004, the rate of reported gonorrheal infections was 113.5 per 100,000 persons."