The Impact of Rapid Drug Susceptibility Tests on Gonorrhea Burden and the Life Span of Antibiotic Treatments: A Modeling Study Among Men Who Have Sex With Men in the United States.

Rapid point-of-care tests that diagnose gonococcal infections and identify susceptibility to antibiotics enable individualized treatment. This could improve patient outcomes and slow the emergence and spread of antibiotic resistance. However, little is known about the long-term impact of such diagnostics on the burden of gonorrhea and the effective life span of antibiotics. We used a mathematical model of gonorrhea transmission among men who have sex with men in the United States to project the annual rate of reported gonorrhea cases and the effective life span of ceftriaxone, the recommended antibiotic for first-line treatment of gonorrhea, as well as 2 previously recommended antibiotics, ciprofloxacin and tetracycline, when a rapid drug susceptibility test that estimates susceptibility to ciprofloxacin and tetracycline is available. The use of a rapid drug susceptibility test with ≥50% sensitivity and ≥95% specificity, defined in terms of correct ascertainment of drug susceptibility and nonsusceptibility status, could increase the combined effective life span of ciprofloxacin, tetracycline, and ceftriaxone by at least 2 years over 25 years of simulation. If test specificity is imperfect, however, the increase in the effective life span of antibiotics is accompanied by an increase in the rate of reported gonorrhea cases even under perfect sensitivity.

Characterizing the Rise of Disseminated Gonococcal Infections in California, July 2020-July 2021.

BACKGROUND: California has experienced an increase in reported cases of disseminated gonococcal infection (DGI). Given significant morbidity associated with DGI and the ability of Neisseria gonorrhoeae to rapidly develop antibiotic resistance, characterization of these cases can inform diagnosis, management, and prevention of DGI. METHODS: As part of the public health response to increased reports of DGI, we used gonorrhea surveillance data reported to the California Department of Public Health to identify all DGI cases in a geographically-bound region. Standardized case report forms were used to collect epidemiologic risk factors and clinical information obtained from provider/laboratory reports, medical records, and patient interviews. RESULTS: From 1 July 2020 to 31 July 2021, we identified 149 DGI patients among 63 338 total gonorrhea infections, representing 0.24% of gonorrhea cases. Estimated incidence was 0.47 DGI cases per 100 000 person-years. Mean age of DGI patients was 40 years, and 75 (50%) were cisgender men, of whom only 13 were known to have male partners. Where reported, more than one-third (36%) used methamphetamine and nearly one-quarter (23%) experienced homelessness. Clinically, 61% lacked urogenital, pharyngeal, or rectal symptoms; 2 patients died in the hospital. Among 47 isolates from patients with antimicrobial susceptibility testing (AST) results available, all were susceptible to ceftriaxone and cefixime. CONCLUSIONS: Most DGI patients lacked urogenital symptoms and were not among populations for which routine gonorrhea screening is currently recommended. Expanding gonorrhea screening might prevent DGI. Cefixime is likely the best option if transitioning from parenteral to oral therapy when AST results are unavailable.

Neisseria gonorrhoeae cervical spine epidural abscess requiring spinal decompression and instrumented fusion.

Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, and typically presents with either a triad of tenosynovitis, dermatitis and polyarthralgia, or with extra-axial large joint septic arthritis. Spinal epidural abscess is a rare manifestation of DGI, with only a few previously reported cases, none of which required placement of metalware into the infected space. Here we report a severe case of isolated N. gonorrhoeae cervical spine epidural abscess necessitating surgical source control (C7/T1 laminectomy and debridement) and metalware placement (C6-T2 posterior instrumented fusion). The case was successfully managed by a combination of surgical intervention followed by six weeks of predominantly oral, targeted antimicrobial therapy.

Clinical Study on Gonococcal Infection of the Penile Raphe.

INTRODUCTION: Gonococcal infection of the penile raphe is rarely encountered in the clinical setting. The study aimed to understand the incidence, sites, clinical manifestations, and treatment of gonococcal infection of the penile raphe. METHODS: We enrolled men with gonococcal infection of the penile raphe and men with urethral gonorrhea from January 2010 to December 2021. All patients' demographic data and clinical characteristics were recorded. All patients were treated with ceftriaxone. Incision and drainage were performed in patients with non-ruptured abscesses. Nodules and sinus tract-like lesions that did not resolve after 1 month of treatment were excised. RESULTS: Among 2,736 men who presented with urethral gonorrhea from January 2010 to December 2021, 5 (0.18%) had accompanying gonococcal infection of the penile raphe. An additional two men presented with gonococcal infection of the penile raphe without urethritis. Thus, 7 (0.26%; confidence interval, 0.11-0.56%) of 2,738 men had urethral gonorrhea or gonococcal infection of the penile raphe confirmed both clinically and by laboratory testing. Lesions were present in the frenulum of the prepuce and at the median aspect, proximal end, distal end, and both the proximal and distal ends of the penile raphe. The lesions manifested as abscesses, ulcers, a nodule, and a nodule with a sinus-like lesion. All lesions exhibited tenderness. All seven patients were cured after treatment. CONCLUSION: Gonococcal infection of the penile raphe is a rare, atypical type of involvement of the male urogenital tract by Neisseria gonorrhoeae. It may be a local complication of urethral gonorrhea or an independent primary infection. The proximal end, distal end, and median aspect of the penile raphe can be infected by N. gonorrhoeae. Cutaneous lesions present as abscesses, ulcers, nodules, and sinus-like lesions. Ceftriaxone is effective, but sinus-like lesions require surgery.

Evaluation of the Hologic Aptima Combo 2 Assay for Detection of Neisseria gonorrhoeae from Joint Fluid Specimens.

Gonorrhea is a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae. Nucleic acid amplification testing is the preferred method for routine diagnosis of gonorrhea from urogenital specimens, but culture is commonly used for diagnosis of disseminated infections, including gonococcal arthritis. The Hologic Aptima Combo 2 (AC2), a transcription-mediated amplification assay, is FDA and Health Canada licensed for detection of N. gonorrhoeae and Chlamydia trachomatis from urogenital, rectal, and pharyngeal specimens, but not joint fluid. In the current study, we compared the performance of microscopy, culture, and the AC2 for detection of N. gonorrhoeae from 170 joint fluid specimens. A total of five specimens were culture-positive, whereas 14 were AC2-positive. Gram-negative diplococci, characteristic of Neisseria, were observed in only two joint fluid specimens. Complementary testing confirmed the presence of N. gonorrhoeae in seven discordant (i.e., culture-negative/AC2-positive) specimens. These results indicate that the AC2 is more sensitive than culture for the diagnosis of gonococcal arthritis.

16S ribosomal assay for early diagnosis of gonococcal meningitis with negative CSF culture: A case report.

Gonococcal meningitis is an exceedingly rare infectious disease, and if not diagnosed and treated in time, it can be severe. We present a case of gonococcal meningitis occurring in a 31-year old healthy woman. She was admitted with fever and persistent headache without urogenital symptoms. Blood cultures were positive and identified as N.gonorrhoeae, but CSF and cervical secretions cultures were both negative. Further testing confirmed the presence of N.gonorrhoeae by 16S ribosomal gene amplification and sequencing in all samples. These results suggest that the case may be a disseminated infection caused by untreated gonorrhea. Our case also shows that nucleic acid detection plays an important role in the rapid and precise diagnosis of gonococcal meningitis and in finding the origin of the pathogen.

[Gonococcal pharyngitis]. / Gonokokkovyi faringit.

A description of a clinical case of oligosymptomatic pharyngitis associated with Neisseria gonorrhoeae is presented. On the example of oligosymptomatic localized gonococcal pharyngitis in a sexually active young man, included in the risk group for extragenital forms of sexually transmitted infections, an advantage has been shown molecular biological diagnostic method. Study of the spectrum of microflora of the oropharynx and urethra with assessment sensitivity to antibacterial drugs of representatives of the genus Neisseria isolated during mixed infection oropharynx, demonstrated that non-pathogenic Neisseria species are resistant to cephalosporins III-IV generations. Unrecognized forms of oropharyngeal gonococcal infection, as a consequence of the complications of clinical and diagnostic identification when patients refer to an otolaryngologist or dermatovenerologist, can serve a reservoir of resistant N. gonorrhoeae and a source of intractable gonococcal infection.

A case of gonococcal meningitis caused by Neisseria gonorrhoeae MLST ST7363 in a healthy young adult.

A 37-year-old healthy man was admitted with fever, skin rash, migratory arthralgia, and headache without preceding urogenital symptoms. Sexual contact history and positive CSF culture for Neisseria gonorrhoeae using BacT/Alert blood culture bottles were diagnostic for gonococcal meningitis. Multilocus sequence typing of this isolate showed sequence type (ST) 7363, the most predominant ST among ceftriaxone-resistant strains. The isolate from this case remained susceptible to ceftriaxone although it was resistant to penicillin, tetracycline, and ciprofloxacin. With the high selective pressure of ceftriaxone for treatment of plasmid-mediated ß-lactamase producing N. gonorrhoeae, resistance to ceftriaxone and molecular characteristics should be monitored.

[Etiology of purulent-inflammatory processes in the genital tract: suspicions of clinicians and problems of laboratory confirmation.]

Despite the long history of the study, laboratory diagnosis of gonococcal infection remains a complex task that does not have a clearly regulated effective solution. Aim of investigation was to assess the species diversity of the microbiota of the genital tract of men and women with suspected acute genital gonococcal infection (AGGI) using test systems of Russian manufacturers. A study of samples of the contents of the urethra of 69 men and posterior vaginal fornix fluids of 33 women of reproductive age with characteristic clinical manifestations and a presumptive diagnosis of AGGI was made. Cultivation was carried out using elective culture media with subsequent identification of strains by biochemical properties. Detection of DNA of Neisseria gonorrhoeae, Staphylococcus spp., Streptococcus spp., Enterobacteriaceae, Gardnerella vaginalis, Atopobium vaginae, Lactobacillus spp. performed by PCR using Vektor-Best and InterLab Service kits (Russia). All patients were divided into groups according to the results of the bacteriological method and PCR. A metagenomic study of 16S ribosomal RNA samples was performed on the Illumina MiSeq platform using the MiSeq Reagent Kits v3 kit (600-Cycle Kit). Statistical analysis of the data was performed using criterion x2. As a result of a laboratory study, the presumptive clinical diagnosis of «AGGI¼ found its bacteriological confirmation in 35.3% of cases only, among which fragments of the N. gonorrhoeae genome were detected in 63.9% of the samples only. Moreover, a wide variety of microorganisms in the genital tract of both men and women was found in metagenomic analysis. However, this technique does not allow us to assess the viability of the detected bacteria, and the microflora spectrum is excessively wide. In addition, the high level of genetic polymorphism of different strains of N. gonorrhoeae complicates the interpretation of the results. Deciphering the composition of microbiota allows the use of InterLab Service kits. The decoding of the etiology of purulent-inflammatory processes in the genital tract, which presents serious difficulties, is greatly facilitated by the use of Russian kits for molecular genetic analysis, which, in our opinion, provide the necessary and sufficient information for practice.

Disseminated Gonococcal Infections in Patients Receiving Eculizumab: A Case Series.

BACKGROUND: Gonorrhea is the second most commonly reported notifiable condition in the United States. Infrequently, Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI). Eculizumab, a monoclonal antibody, inhibits terminal complement activation, which impairs the ability of the immune system to respond effectively to Neisseria infections. This series describes cases of N. gonorrhoeae infection among patients receiving eculizumab. METHODS: Pre- and postmarketing safety reports of N. gonorrhoeae infection in patients receiving eculizumab worldwide were obtained from US Food and Drug Administration safety databases and the medical literature, including reports from the start of pivotal clinical trials in 2004 through 31 December 2017. Included patients had at least 1 eculizumab dose within the 3 months prior to N. gonorrhoeae infection. RESULTS: Nine cases of N. gonorrhoeae infection were identified; 8 were classified as disseminated (89%). Of the disseminated cases, 8 patients required hospitalization, 7 had positive blood cultures, and 2 required vasopressor support. One patient required mechanical ventilation. Neisseria gonorrhoeae may have contributed to complications prior to death in 1 patient; however, the fatality was attributed to underlying disease per the reporter. CONCLUSIONS: Patients receiving eculizumab may be at higher risk for DGI than the general population. Prescribers are encouraged to educate patients receiving eculizumab on their risk for serious gonococcal infections and perform screening for sexually transmitted diseases (STDs) per the Centers for Disease Control and Prevention STD treatment guidelines or in suspected cases. If antimicrobial prophylaxis is used during eculizumab therapy, prescribers should consider trends in gonococcal antimicrobial susceptibility due to emerging resistance concerns.

Gonococcal cellulitis: an (un)friendly bite.

BACKGROUND: Gonococcal infection can present with wide spectrum of symptoms, most commonly involving the genitals. This case highlights a rare presentation of Neisseria gonorrhoeae infection primarily with skin involvement without uro-genital disease. CASE: A 33-year-old male was admitted to the hospital with complaints of painful swelling of his penis. In the emergency room, he underwent incision and drainage of the abscess under local anaesthesia. After microbiological evaluation, he was found to have skin abscess caused by N. gonorrhoeae and was treated with intravenous ceftriaxone and changed to oral agent amoxicillin-clavulanate with complete resolution. CONCLUSION: The manifestations of gonococcal infection have changed significantly over the last few years, with more involvement of extra genital sites attributed to changes in sexual practices. Our patient was treated for cellulitis and abscess caused by N. gonorrhoeae in the absence of systemic or urethral disease. Recommendations regarding treatment of gonococcal infection have been widely published. However, there is a paucity of evidence-based guidelines regarding the therapy of primary cutaneous gonococcal infection. Pooled data from similar cases may help determine the optimum therapy.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound.

BACKGROUND: Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis. CASE REPORT: A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 103/µL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

A Meta-analysis to Quantify the Risk of Disseminated Gonococcal Infection With Porin B Serotype.

The escalating rates of gonorrhea globally are associated with higher numbers of disseminated gonococcal infection (DGI). Expression of the PorB1A allele of the major outer membrane porin protein, PorB, is associated with DGI. This meta-analysis shows that the odds of PorB1A strains to disseminate is 20.53 compared to PorB1B isolates.

Gonococcal endocarditis in a 32-year-old male: a rare presentation of an underrecognized disease - case report.

Introduction and importance: Disseminated gonococcal infection (DGI) is an infrequent but serious complication of gonorrhea that can exhibit atypical symptoms. While rare, it can lead to infective endocarditis (IE), a condition that affects the heart valves and can result in severe and potentially life-threatening outcomes. Case presentation: We present a case of Neisseria gonorrhoeae-caused IE confirmed by blood culture and direct isolation from the aortic valve vegetation. Our patient experienced complications, including glomerulonephritis, respiratory failure, and positive troponin. Urgent surgery successfully removed a large vegetation, replaced the aortic valve, and improved cardiac function. Follow-up showed symptom resolution. Clinical discussion: DGI can present atypically with a triad of tenosynovitis, polyarthralgia, and rash, even without genitourinary symptoms. However, it can also present with nonspecific symptoms, leading to a later diagnosis of IE, as observed in our patient, who developed an aortic valve abscess and aortic regurgitation. Conclusion: This case provides important insights into the diagnosis and management of gonococcal endocarditis, emphasizing the significance of early recognition, timely intervention, and multidisciplinary collaboration in improving patient outcomes. It is imperative to have a high level of suspicion for this rare entity, given its high virulence and potential for severe complications.

Australian Gonococcal Surveillance Programme Annual Report, 2022.

The Australian Gonococcal Surveillance Programme (AGSP) has continuously monitored antimicrobial resistance in Neisseria gonorrhoeae for more than 40 years. In 2022, a total of 8,199 isolates from patients in the public and private sectors, in all jurisdictions, were tested for in vitro antimicrobial susceptibility by standardised methods. The current treatment recommendation for gonorrhoea, for the majority of Australia, continues to be dual therapy with ceftriaxone and azithromycin. In 2022, of N. gonorrhoeae isolates tested, 0.51% (42/8,199) met the WHO criterion for ceftriaxone decreased susceptibility (DS), defined as a minimum inhibitory concentration value ≥ 0.125 mg/L. Resistance to azithromycin was reported in 3.9% of N. gonorrhoeae isolates, proportionally stable since 2019. There were nine isolates with high-level resistance to azithromycin (MIC value ≥ 256 mg/L) reported in Australia: Queensland (4), New South Wales (3), Victoria (1) and non-remote Western Australia (1). This is the highest number detected annually by the AGSP. In 2022, penicillin resistance was found in 38.8% of gonococcal isolates, and ciprofloxacin resistance in 63.3%, however, there was considerable variation by jurisdiction. In some remote settings, penicillin resistance remains low; in these settings, penicillin continues to be recommended as part of an empiric therapy strategy. In 2022, in remote Northern Territory, one penicillin-resistant isolate was reported; in remote Western Australia, 11.8% of gonococcal isolates (9/76) were penicillin resistant. There were three ciprofloxacin-resistant isolates reported from remote Northern Territory; ciprofloxacin resistance rates remain comparatively low in remote Western Australia (6/76; 7.9%).

Disseminated gonococcal infection of the shoulder mimicking rheumatoid arthritis.

Introduction: Gonococcal arthritis is a characteristic of disseminated gonococcal infection (DGI). DGI arthritis is one of the most serious orthopedic emergencies because it can result in rapidly progressive joint damage, but it is often difficult to diagnose. Delayed treatment can result in the development of osteomyelitis in the adjacent bone, similar to other types of bacterial arthritis. Method: We report a case of gonococcal osteomyelitis associated with DGI that was initially treated as rheumatoid arthritis. The diagnosis was confirmed by DNA testing of synovium collected during arthroscopic debridement. Results: Seven years after the initial consultation, there was no acute-phase reactant, the arthritic changes had improved over time and the range of motion had increased. DGI may be difficult to confirm, but it is one of the most important entities that should be differentiated in the treatment of arthritis. Conclusion: Clinicians need to keep in mind that blood and synovial fluid cultures often do not lead to a definitive diagnosis.

Disseminated Gonococcal Infection Due to a Mediport Catheter Infection.

Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae and has a wide clinical spectrum that can range from asymptomatic to disseminated disease. Most women with gonorrhea are asymptomatic and if left untreated, it can lead to serious complications like pelvic inflammatory disease (PID) and infertility. Disseminated gonococcal infection (DGI) is usually characterized by dermatitis, tenosynovitis, and septic arthritis but rarely can also cause bacteremia, endovascular infections, osteomyelitis, and meningitis. Gonococcal bacteremia is regarded as a disseminated disease and is typically associated with infection of the mucosal surfaces such as the urethra, endocervix, and pharynx. This report, to the best of our knowledge, presents a case of DGI associated with a mediport catheter in a patient with breast cancer without any history of gonococcal symptoms. She was monogamous and denied any history of sexually transmitted infections. The patient presented with fever and chills associated with pain and purulent discharge from the mediport catheter site. The mediport catheter was removed, and antibiotics were initiated. Both blood and wound cultures grew N. gonorrhoeae. She completed a 10-day course of ceftriaxone and improved clinically with complete remission of her symptoms. A review of the literature on the reported cases of DGI associated with bacteremia and endovascular infections is also presented.