In the preantibiotic era, gonorrhea usually persisted for two to three months before host defenses finally eradicated the infection. These defenses include serum opsonic and bactericidal antibodies, as well as mucosal antibodies of the IgG and IgA classes. All gonococci produce IgA1 protease, an enzyme that inactivates the major class of secretory IgA, perhaps contributing to persistence of mucosal infection.
Most cases of pharyngeal gonococcal infection resolve spontaneously, and transmission from the pharynx to sexual contacts is rare.
During the 20 years before 1976, all N. gonorrhoeae strains were sensitive to penicillin, but a gradual increase had been noted in the mean MIC (13). The first reports of penicillinase-producing N. gonorrhoeae (PPNG) arising in the Far East occurred in the 1970s. PPNG strains have accounted for more than 30% of isolates of N. gonorrhoeae in the United States. There has also been a similar increase in tetracycline-resistant N. gonorrhoeae. These resistant strains cause the same disease spectrum as penicillinsensitive organisms. In 1983 an outbreak of chromosomally mediated penicillin-resistant gonococci was reported from North Carolina; subsequently, it has occurred in other areas of the country. Although strains of N. gonorrhoeae with decreased susceptibility to ceftriaxone do occur, no documented clinical treatment failures have been observed related to decreased gonococcal susceptibility to ceftriaxone in the United States.
Routine preventive prophylaxis of gonococcal ophthalmia includes (i) 1% silver nitrate (with no irrigation with saline solution, which might reduce efficacy) and (ii) ophthalmic ointments containing tetracycline (1%) or erythromycin (0.5%), per the 2002 CDC guidelines. Use of bacitracin ointment (not effective) and penicillin drops (sensitizing) is not recommended. Data on use of povidone-iodine are limited; initial studies suggested less efficacy. Silver nitrate is no longer manufactured in the United States. Systemic therapy is imperative. Patients are hospitalized and given hourly eyewashes with normal saline until discharge is eliminated. This reduces the bacterial load and forces hourly monitoring of the cornea.
The infant born to a mother with untreated gonorrhea should have orogastric and rectal cultures taken routinely and blood cultures taken if the infant is symptomatic. A full-term infant should receive a single injection of ceftriaxone [50 mg/kg intravenously (IV) or intramuscularly (IM), not to exceed 125 mg]. Although ceftriaxone is not usually given to newborn infants, it is indicated in this specific setting.
The first-line regimen for treatment of uncomplicated gonococcal infection in adults recommended by the CDC 2002 guidelines is cefixime (400 mg orally, single dose); ciprofloxacin (500 mg orally, single dose); single-dose ceftriaxone (125 mg IM); or a single-dose oral quinolone (ciprofloxacin, 500 mg, ofloxacin, 400 mg, levofloxacin, 250 mg, or gatifloxacin, 400 mg). However, cefixime is no longer available, as the manufacturer ceased production in 2002. Spectinomycin is not as effective in treating pharyngeal gonorrhea. Each regimen should also include a regimen effective against possible coinfection with Chlamydia trachomatis such as azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally, two times a day for seven days). Recent data from the CDC's Gonococcal Isolate Surveillance Project from several sites in California are also demonstrating an increased prevalence of quinolone resistance in the state and further suggest that use of quinolones in California is probably not advisable.
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