STIs - Epidemiology/Gonorrhea

• Know the pathogen and method of transmission of each sexually transmitted infection (STI)

• Recognize clinical presentation and diagnosis of each STI

• Discuss treatment and monitoring of each STI

• Identify important patient counseling points for each STI and treatment regimen

Learning Objectives

• Gonorrhea

• Chlamydia

• Syphilis

• Cancroid

• Granuloma inguinale

• Bacterial vaginosis

• Lymphogranuloma venereum

GCS

What are the STIs that are bacterial ?

• Human immunodeficiency virus (HIV)

• Herpes simplex virus (HSV)

• Human papillomavirus (HPV)

• Mpox

• Hepatitis

HSV only

What are the STIs that are viral ?

Fungal

• Vaginal candidiasis

Protozoal

• Trichomoniasis

What are the fungal and Protozoal STIs?

• Gender assigned at birth (males > females)

• Young people aged 15-24 years

• Multiple or anonymous sexual partners

• Unprotected sex (anal, vaginal or oral)

• History of STIs

• Having sex while under the influence of drugs/alcohol

STI risk factors

• Abstain from vaginal, oral, or anal sex

• Minimize number of partners

• Pre-exposure vaccination

• Regular STI testing

• Barrier contraceptive methods

Prevention of STIs points

• Partners

• Practices

• Protection from STIs

• Past History of STIs

• Pregnancy Intention

How do you collect the patients sexual history?

• Second most reported STI

• 550,000 cases in US in 2024

• Risk of infection after single exposure

  • more so female

  • males less so

Gonorrhea epidemiology

• Causative organism: Neisseria gonorrhea (gram-negative diplococci)

• Infects and invades mucosa of the urethra, endocervix, anorectum, pharynx and conjunctiva

• Transmission 

  • Sexual contact (vaginal, anal, oral)

  • Maternal-infant (vaginal delivery)

• Incubation period: 1-14 days

• Symptom onset: 2-10 days

• Chlamydia co-infection is common

  • 50% in females

  • 20% in males

Gonorrhea pathophysiology

• Symptomatic or asymptomatic

• Urethral/cervical: dysuria, urinary frequency, discharge, uterine bleeding

• Anorectal: discharge, itching, pain

• Pharyngeal: erythema, pain, sore throat

• Conjunctival: pain, purulent discharge

Clinical presentation of Gonorrhea

• Screening

  • Sexually active females < 25 years (annual)

  • Females > 25 years with risk factors (annual)

  • Men who have sex with men (MSM); sexually minority men (SMM) (at least annually)

  • Pregnant persons (1^st prenatal visit and during 3^rd trimester if risk)

• Clinical signs and symptoms

• Nucleic acid amplification tests (NAATs) – Recommended primary diagnostic and screening test

  • High sensitivity, rapid results

  • Limitation: no resistance data

Ways to diagnose gonorrhea part 1

• Gram-stain

  • Lower sensitivity

• Culture 

  • Suspected or documented treatment failure

  • Test of cure if alternative treatment regimen used

  • If evaluating for disseminated infection

Ways to diagnose gonorrhea part 2

Ceftriaxone IV/IM 500 mg once

if* patient weighs >150 kg = 1 g

Recommended treatment regimen for uncomplicated gonorrhea (in the cervix, urethra, rectum, pharynx)

• Gentamicin IV/IM 240 mg + Azithromycin PO 2 g once (cephalosporin allergy)

• Cefixime PO 800 mg once (not in pharynx)

ALTERNATIVE treatment regimen for uncomplicated gonorrhea (in the cervix, urethra, rectum, pharynx)

Ceftriaxone IV/IM 1-2g q 12-24 hours for > 7 days

• based on site of infection

No alternative regimen

Recommended treatment regimen for disseminated gonorrhea

Ceftriaxone IV/IM 1g

No alternative regimen

Recommended treatment regimen for conjunctivitis gonorrhea

Ceftriaxone IV/IM 25-50 mg/kg once (max 250 mg)

No alternative regimen

Recommended treatment regimen for opthalmia neonatorum-gonorrhea

Erythromycin (0.5%) ophthalmic ointment once postpartum

no alternative regimen

Recommended treatment regimen for Infants born to mothers with gonococcal infection (prophylaxis)

add doxycycline PO 100 mg BID x 7 days (azithromycin PO 1 g once in pregnancy) 

How do you treat gonorrhea/what do you add if co-infection chlamydia cannot be excluded?

• Males (rare): acute epididymitis, prostatitis, inguinal lymphadenopathy, urethral stricture

• Females: pelvic inflammatory disease (PID) occurs in 10-20%

  • Associated complications (i.e. ectopic pregnancy)

• Infertility

• Conjunctival infection: corneal scarring, blindness

• Disseminated infection (0.5-3%): skin lesions, meningitis, septic arthritis, endocarditis

Gonorrhea complications