Zambian HIV Guidelines:: Neisseria gonorrhoeae

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Neisseria gonorrhoeae

Khalil G. Ghanem, M.D.
02-14-2008

All patients with gonorrhea should be offered routine counseling and testing for HIV infection.
Dx based on syndromic presentation; Cx, hybridization probes, NAATs not routinely available.
Recent report from S. Africa found resistance to penicillin: 16%; tetracycline: 36%; ciprofloxacin: 7%.
Rates of resistance not published for Zambia; uinolone resistance has risen elsewhere in the world but not well-documented in Africa.
Recommended Rx in Zambia: Adults - ciprofloxacin 500 mg PO x1; Pregnancy - spectinomycin 2g IM x1; Children and adolescents (<17 yrs old) - spectinomycin 40 mg/kg IM x1 (maximum of 2g).
Alternative Rx in Zambia: Adults - spectinomycin 2g IM x1 OR cefixime 400 mg PO x1; Pregnancy - cefixime 400 mg PO x1 OR ceftriaxone 250 mg IM x1; Children and adolescents (<17 yrs old) - ceftriaxone 125 mg IM x1 (if > 45 kg, use adult dose) OR cefixime 8 mg /kg PO x1 (if > 45 kg, use adult dose).

Zambia Information Author: David Riedel, M.D.

MICROBIOLOGY

Non-motile, non-spore-forming, gram-negative diplococcus
Infects cuboidal & columnar epithelium leading to a vigorous PMN response.
Selective growth media (Thayer-Martin & New York City) most common; Cx still considered standard in Dx of GC infection in settings that can process specimens appropriately. Swabs from urethral, cervical, rectal, pharyngeal, & ocular sites can be Cx'd.
Non-amplified molecular testing, including EIA & DNA hybridization probes, are most commonly used Dx methods. Cervical & urethral swabs can be tested.
Nucleic acid amplification tests (NAATs), including PCR, strand displacement assay (SDA), & transcription-mediated amplification (TMA), may be performed on urethral swabs, cervical swabs, urine, & self-collected vaginal swabs.

Sx in men: acute urethritis (purulent urethral discharge, dysuria) is predominant manifestation; incubation 2-7d; 10% of epididymitis in young men due to GC; asymptomatic infection less common than in women (up to 30%)
Sx in women: asymptomatic (up to 90% in some studies); vaginal discharge, dysuria, spotting. PID is serious complication of ascending infection.
Anorectal: May be only site of infection in up to 40% of MSM & 5% of women. Sx may include tenesmus, purulent discharge, & rectal bleeding, though most asymptomatic.
Disseminated GC infection (DGI): asymmetrical migratory polyarthritis (knees, elbows), tenosynovitis, & dermatitis (hemorrhagic papules/pustules); blood Cx positive in 50%; >80% of mucosal Cx are positive; joint fluid findings: >50,000 PMNs & Cx usually positive.
Gram stain (urethra) >90% sensitive in symptomatic men, less sensitive (40-60%) in women (endocervical site) & asymptomatic men (~50-70% sens); NAATs have >95% sensitivity & ~99% specificity in both symptomatic & asymptomatic pts.
NAATs from oropharyngeal or rectal sites not currently FDA licensed; Cx is standard diagnostic test.

GU: urethritis, epididymitis, cervicitis, Skene's & Bartholin's gland infections, endometritis, salpingitis, pelvic peritonitis & tubo-ovarian abscess.
CV: DGI ; endocarditis (rare)
GI: gingivitis (rare), pharyngitis, proctitis, & perihepatitis (Fitz-Hugh-Curtis syndrome).
Musculoskeletal: osteomyelitis (rare) & septic arthritis
Eyes: conjunctivitis.
CNS: meningitis (very rare)

Drug Resistance

~18% of strains in the U.S. resistant to PCN, TCN, or both.
Fluoroquinolone-resistant N. gonorrhoeae (FQRNG) strains are widespread in Asia, Pacific islands (Hawaii), California, England, & Wales.
Increase in FQRNG in men who have sex w/ men (MSM) throughout U.S. in 2003 (~5% of isolates among MSM) .
Increase in azithromycin resistance in the past several years (~3% in 2002)
Cephalosporin (ceftriaxone and cefixime) resistance in U.S. very low.

General Principles

Prevention: condoms highly effective at preventing transmission.
Treatment recommendations for HIV-infected pts similar to uninfected pts.
Single dose therapy is preferred.
PCN & TCN should not be used
FQs should not be used to treat pts who have traveled (or whose partners have traveled) to areas w/ high rates of FQRNG (see above)
FQs should not be used to treat infections in MSM
Treat for concomitant Chlamydia trachomatis infection with doxycycline 100 mg PO bid x 7d OR azithromycin 1 g PO x1 dose unless Chlamydia definitively ruled out by NAATS.

Antimicrobial Therapy

From: CDC. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006:55 (No. RR-11)
Uncomplicated urethral, cervical, anorectal, & oropharyngeal infections: ceftriaxone 125 mg IM x1 OR cefixime 400 mg PO x1 OR ciprofloxacin 500 mg PO x1 OR ofloxacin 400 mg PO x1 PLUS C. trachomatis therapy (see above).
Spectinomycin 2 g IM (if oropharyngeal infection consider test of cure).
DGI: ceftriaxone 1 g IV q12h OR ciprofloxacin 500 mg IV q12h until clinical response, then switch to PO cefixime 400 mg bid OR ciprofloxacin 500 mg bid to complete a 7d course.
GC conjunctivitis: ceftriaxone 1 g IM x1
PID outpatient: ceftriaxone 250 mg IM x1 + doxycycline 100 mg PO bid +/- metronidazole 500 mg PO bid x14 d OR levofloxacin 500 mg PO qd + metronidazole 500 mg PO bid x14 d
PID inpatient: clindamycin 900 mg IV q8h + gentamicin 2 mg/kg IV x1 loading, then 1.7mg/kg IV q8h (monitor levels) once daily gentamicin (5 mg/kg) OR cefotetan 2 g IV q12h + doxycycline 100 mg IV/PO q12h. Can switch to PO doxycycline 24-48 hrs after clinical improvement to complete a 14 d course.

Drug	Recommendations/Comments
Azithromycin	1 g used for co-treatment of C. trachomatis not adequate for GC. 2 g dose FDA-approved for GC but cost and high rate of GI distress limit clinical applicability.
Ceftriaxone	No clinically significant resistance to ceftriaxone documented in U.S.
Ciprofloxacin	Not to be used in MSM or in pts who have traveled to California, Hawaii, or Asia.
Spectinomycin	Less effective cure rates for oropharyngeal GC.

No test of cure necessary after Rx
Repeat NAATs should not be performed within 2 wks after Rx as persistent nucleic acid can give false-positive results.
All sex partners in past 60 d should be tested and treated presumptively if follow-up uncertain.
Persistent Sx despite adequate therapy & no re-exposure warrants Cx with susceptibility testing
Outpatient Rx of PID warrants F/U within 72 hrs to ensure clinical improvement.

Updated information on gonorrhea can be found at: http://www.cdc.gov/std/Gonorrhea/

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