162.1 🎓 醫孞生版

162.1.0.1 📌 䞀頁重點

  • 菌: N. gonorrhoeae — Gram - kidney bean diplococcus, oxidase +, glucose only fermenter (vs N. meningitidis glucose + maltose)
  • Reservoir: human only; STI route + perinatal vertical
  • 臚床:
    1. Urethritis (♂): purulent discharge + dysuria; some asymptomatic
    2. Cervicitis / PID (♀): often asymptomatic → infertility + ectopic + chronic pelvic pain
    3. Pharyngitis, proctitis, conjunctivitis (MSM, neonatal)
    4. DGI (Disseminated Gonococcal Infection): dermatitis + tenosynovitis + arthritis (or purulent monoarthritis)
    5. Ophthalmia neonatorum (delivery 出生 2-5d)
  • 2020 CDC update: Ceftriaxone 500 mg IM × 1 (doubled from 250 due MIC creep); + doxy 100 bid × 7d for likely co-infected chlamydia (if not yet ruled out)
  • 抗藥: emerging XDR (Asia, esp Japan/China/UK travelers); high-level FQ R, azithro R
  • Future drugs: zoliflodacin (2024 FDA submission), gepotidacin (2024 FDA approved)
  • Test of cure: 通垞䞍必 (陀非 pharyngeal 或抗藥嫌); screening 高 risk: MSM, 青少幎, prior STI, multiple partners

162.1.0.2 1⃣ 现菌孞

  • Gram - kidney bean diplococcus
  • Oxidase +
  • Glucose only fermenter (vs N. meningitidis glucose + maltose)
  • Chocolate / Thayer-Martin (selective with vanco, colistin, nystatin)
  • Pili → adhesion to mucosa; antigenic variation → re-infection 可胜
  • Por proteins, Opa, LOS — virulence
162.1.0.2.1 Carriage / Transmission
  • 性接觞䞻芁; 90% gonococcal pharyngitis asymptomatic
  • 母 → 新生兒 (產道)

162.1.0.3 2⃣ 臚床衚珟

162.1.0.3.1 A. ♂ Urethritis
  • 望䌏 2-7d
  • Purulent discharge + dysuria
  • 郚分 asymptomatic (subclinical)
  • Complications: epididymitis, prostatitis (rare), urethral stricture
162.1.0.3.2 B. ♀ Cervicitis + PID
  • 倧倚 asymptomatic (vs Chlamydia 䞀暣)
  • Mucopurulent discharge, post-coital bleeding, dysuria
  • PID: 䞋腹痛, motion tenderness, fever; → TOA (tubo-ovarian abscess), 䞍孕, 匂䜍劊嚠, chronic pelvic pain (Fitz-Hugh-Curtis liver capsule)
162.1.0.3.3 C. Pharyngitis
  • MSM / 口亀; mostly asymptomatic
  • 治療 harder (lower drug penetration)
162.1.0.3.4 D. Proctitis (MSM, receptive 性亀)
  • 痛, discharge, tenesmus
162.1.0.3.5 E. Conjunctivitis
  • Adult: 自己手指接 (autoinoculation)
  • Ophthalmia neonatorum: delivery 2-5d 埌; 緊急 — corneal scarring, blindness; topical erythromycin 預防 (USA universal, Taiwan public health)
162.1.0.3.6 F. DGI (Disseminated Gonococcal Infection)
  • 0.5-3% of mucosal gonorrhea
  • Female > Male; menstrual / post-menstrual
  • 2 patterns (overlapping):
    1. Triad: tenosynovitis + dermatitis (pustular/hemorrhagic peripheral) + polyarthralgia (migratory)
    2. Purulent monoarthritis (knee 垞芋)
    • low-grade fever, malaise
  • Endocarditis rare (subacute, valve damage)
  • Meningitis rare
  • Complement deficiency (C5-C9, properdin) - recurrent DGI

162.1.0.4 3⃣ 蚺斷

162.1.0.4.1 NAAT (Nucleic Acid Amplification Test) — Gold Standard
  • Urine, urethral, endocervical, vaginal swab, pharyngeal, rectal
  • Sensitivity / specificity 高
  • 同 sample 可 test 同時 chlamydia (combo)
162.1.0.4.2 Culture
  • 仍需芁 for AST (susceptibility) — 抗藥 concern
  • Thayer-Martin selective
  • Pharyngeal / rectal cx: 范 NAAT 䞍 sensitive
162.1.0.4.3 Gram Stain
  • Urethral discharge ♂: high sensitivity (gram - diplococci in PMN)
  • Endocervical ♀: low sensitivity
162.1.0.4.4 Other Tests + Workup
  • 同時 HIV + syphilis + chlamydia + HBV screen
  • 通報 (notifiable disease)
  • Partner notification (Public Health partner services)

162.1.0.5 4⃣ 治療 (CDC 2020 + 2024 update)

162.1.0.5.1 A. Uncomplicated Urethritis / Cervicitis / Rectal / Pharyngeal
  • Ceftriaxone 500 mg IM × 1 (doubled from 250 mg due MIC creep)
    • ≥ 150 kg: 1 g IM
  • + Doxycycline 100 mg PO bid × 7d (if chlamydia not ruled out)
  • Azithromycin — 䞍再 routine (R 䞊升)
162.1.0.5.2 B. Severe / 過敏 / Cephalosporin-Allergy
  • Gentamicin 240 mg IM + Azithromycin 2 g PO × 1
  • Gepotidacin (2024 FDA approved) — new option
  • Allergy testing for cephalosporin (cross-react low with ceftriaxone)
162.1.0.5.3 C. DGI
  • Ceftriaxone 1 g IV/IM q24h × 7d (after sx improve, can switch oral if susceptible)
  • Joint drainage if purulent monoarthritis
162.1.0.5.4 D. Endocarditis / Meningitis (Rare)
  • Ceftriaxone 1-2 g IV q12h × 4-6 wk
162.1.0.5.5 E. Ophthalmia Neonatorum
  • Ceftriaxone 25-50 mg/kg IV/IM × 1 (max 250 mg)
    • 県 irrigation
  • Mother + partner treat
162.1.0.5.6 F. Pregnancy
  • Ceftriaxone 500 mg IM × 1
    • Azithromycin if Chlamydia (doxy contraindicated pregnancy)
162.1.0.5.7 G. Test of Cure
  • 通垞䞍必 (uncomplicated genital with ceftriaxone)
  • Pharyngeal infection: test of cure 7-14d (NAAT) — 范高 failure
  • 抗藥 嫌疑或 persistent sx → re-test
  • Re-screen 3 mo (recommended high-risk for re-infection)
162.1.0.5.8 H. EPT (Expedited Partner Therapy)
  • USA legal in most states
  • Partner 治療 without 醫垫 visit
  • Cefixime 800 mg PO + doxy 100 bid × 7d
  • Taiwan 䞍正匏 EPT but partner notification 重芁

162.1.0.6 5⃣ 抗藥 — 珟況 + Future

  • PCN, tetracycline, FQ: 普遍 R (USA, Taiwan ~ 95% FQ R)
  • Azithromycin: rising R
  • Ceftriaxone: emerging MIC creep, 2020 dose doubled
  • XDR cases (resist all): Asia (Japan, China, UK travel cluster)
  • 監枬: GISP (US), GASP (WHO global)
162.1.0.6.1 Future Drugs (2024)
  • Gepotidacin (2024 FDA approved): topoisomerase IIa inhibitor
  • Zoliflodacin (FDA submission 2024): novel topo II/IV inhibitor; phase 3 success
  • Solithromycin (failed FDA 2017, in dev other indications)