Etiologia
- Neisseria gonorrhea
- Reservatório assintomático: faringe
- Metade das transmissões são por sexo oral
Epidemiologia
- Incidência 10-20 casos por 100.000 habitantes
Resistance
- Antigenic variability - transformation of Nesseria gonorrhoeae allows evasion of immune system
- Type IV secretion system of single stranded DNA allows transmission of resistance to other bacteria
- Chromossomal ou plasmid encoded
- Plasmids
- Pla carries beta lacta as e. requires only 1-2 aminoácidos changes to become an extended spectrum beta lactamase (ESBL). Hasn’t happened yet, but can easily be transmitted ig this happened
- High level of tetracycline resistance mediated by tetM- designated “American” (from Africa) and “Dutch” (from Middle East)
- Efflux pump - mechanism of resistance to ceftriaxone. Can be driven by doxycycline, penicillin, azythomycin
- XDR-NG - Extensively drug resistant Neisseria gonorrhoea
- FC428 - initially Japan, Canada, Autralia, spread to Europe and Russia
- DoxyPEP will select for tetracycline resistance. Gonococcus who are ceftriaxone resistant are also most likely also tetracycline resistant. This will most likely select resistant gonococcus
- How big is the resistance problem?
- Challenges: not all countries represented: Africa, Russia, India, Cambodia
- China: some regions already have resistance as well - problem with immigrants
- How do we contain gonococcal antimicrobiano resistance
- Human infection: disease burden, diagnositics, prescriber’s behaviour, consumer’s expectation & adherence
- Antimicronbial agents: regulatory framework, drug procurement, drug quality, drug supply management
Apresentação clínica
- Urethritis (very purulent)
- Purulente greenish-yellow urethral discharge - gonococcal blennorrhagia
- Classic “hot piss”
- Pharyngitis (usually asymptomatic)
- Acute anorectitis (usually asymptomatic)
- Endocervicitis, Pelvic Inflammatory Disease
- Infants: ophthalmia (rapidly leads to blindness if untreated) - nos EUA aplicam silver nitrate or erythromycin ointment in eyes at birth
- Disseminated Gonorrhea/Gonococcal septicemia
- Dermatitis
- Lenticular pustules surrounded by an erythematous halo located on the extremities and in periarticular regions
- Migratory polyarthritis
- Tenosynovitis
- Other visceral involvement: spenomegaly, hepatitis, myocarditis, miningitis, endocarditis
Complications
- Orchiepididymitis
- Prostatitis
- Salpingitis
- Bartholinitis
Diagnóstico
- Gram stain: Gram negative kidney/bean shaped diplococci inside polymorphonuclear cells
- Culture in Thayer Martin (chocolate agar with AB to prevent normal flora from growing)
- NAAT/PCR
Tratamento
- Ceftriaxone 1g IM toma única + Doxiciclina 100mg 12/12 7 dias if chlamydia cannot be excluded
- Alternatives: 800 mg oral dose of cefixime (cíprio Flo acima antigamente)
- Cefixime was thought to be a promise, but resistance fails first than ceftrixaone. Don’t use as 1st line (IUSTI)
- Gepotidacin and Zoliflodacin new drugs. Studies show it is best to use it widely and quickly rather than selectively
- Culturally, Japan avoids intramuscular injections at all cost. Prefer intravenous.
Prevenção
- Meningococcal vaccine some protection - still in study. Use in high risk MSM. Studies are showing population protection but low protection to the individual patient who has to pay for it.
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