Disseminated Gonococcal Infection

Background

• Disseminated gonococcal infection (DGI) is a rare complication of gonorrhea, arising in 0.5%-3% of cases.
• Two major clinical syndromes associated with DGI have been described, however patients may have features of both types.
  • Suppurative form, characterized by septic arthritis
    • may be monoarticular or asymmetric oligoarticular
    • most often involves the knee, wrist, ankle, or interphalangeal finger joints
  • Bacteremic form (arthritis-dermatitis syndrome)
    • characterized by triad of joint pain, skin lesions, and tenosynovitis
    • nonspecific systemic symptoms may also be present, including chills, fever, malaise, and myalgia
• Less common manifestations include hepatitis, endocarditis, and meningitis.
• Though infection is typically sexually transmitted, symptomatic genital infection is not present in many patients presenting with DGI.
• Risk factors for disseminated infection include complement deficiencies, pregnancy, menstruation, intrauterine device use, and immunodeficiency.
• Neisseria gonorrhoeae is capable of rapidly developing antibiotic resistance and extensively drug-resistant strains are emerging worldwide.

Evaluation

• Suspect disseminated gonococcal infection in patients with risk factors for sexually transmitted infection and a compatible syndrome such as
  • mono- or oligoarticular asymmetric arthritis
  • systemic illness, often with arthralgias, tenosynovitis, and maculopapular or pustular skin lesions.
• Diagnosis often clinical but may be confirmed by presence of Neisseria gonorrhoeae in synovial fluid, blood, or other site.
  • Specimens to test include synovial fluid and/or synovium biopsy, blood, rectal and oropharyngeal samples, and specimens from genitourinary sites and/or freshly voided urine. Less commonly, skin lesions or cerebrospinal fluid may also be tested.
  • Laboratory diagnostic tests may include Gram stain, culture, and nucleic acid amplification test.
• Patients with gonorrhea infection should be tested for other sexually transmitted infections including Chlamydia trachomatis, syphilis, and HIV.

Management

• Hospitalization is recommended for initial therapy.
• Recommendations for initial empiric therapy vary among guideline agencies.
  • Centers for Disease Control and Prevention (CDC) recommendations
    • for management of arthritis and arthritis-dermatitis syndrome in adults
      • recommended therapy
        • ceftriaxone 1 g intramuscularly or IV every 24 hours
        • if chlamydial coinfection has not been excluded, combination therapy recommended
          • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
          • for pregnant patients, give azithromycin 1 g orally in single dose
      • alternative regimens
        • cefotaxime 1 g IV every 8 hours
        • ceftizoxime 1 g IV every 8 hours
        • if chlamydial coinfection has not been excluded, combination therapy recommended
          • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
          • for pregnant patients, give azithromycin 1 g orally in single dose
    • recommended regimen for management of meningitis and endocarditis in adults is
      • ceftriaxone 1-2 g IV every 24 hours
      • if chlamydial coinfection has not been excluded, combination therapy recommended
        • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
        • for pregnant patients, give azithromycin 1 g orally in single dose
  • European International Union against Sexually Transmitted Infections/World Health Organization recommends ceftriaxone 1 g intramuscularly or IV every 24 hours, cefotaxime 1 g IV every 8 hours, or spectinomycin 2 g intramuscularly every 12 hours.
• Parenteral therapy can be transitioned to oral after 24-48 hours.
  • Definitive therapy should be based on culture and susceptibility testing.
  • Patients with meningitis or endocarditis require extended parenteral treatment.
• Recommended duration of therapy is at least 7 days total, except in patients with meningitis (treat for 10-14 days) or endocarditis (treat for at least 4 weeks).
• Sex partners of patients should be referred for testing and treatment.
• For additional information on management of infected joints, see Septic Arthritis in Adults.