Clinical Significance Of The Diagnosis And Treatment Of Gonorrhea

Gonorrhea should be suspected in all clinical situations where there is purulent urethral diacharge, situations where there is purulent urethral discharge, leucorrhea in women, atypical oropharyngeal ulceration, proctocolitis and ophthalmia neonatorum. Bacteriological diagnosis is established by demonstrating Gram negative diplococcic inside polymorphonuclear cells in the exudates. The organism can be identified by culture and further studies. Culture of cervical discharge is required in women with late manifestations to establish the diagnosis. On rare occasions, purulent material may have to be collected by culdocentesis or laparoscopy. Fluorescent antibody techniques help in making quick diagnosis where such facilities exist. Complement fixation test is useful in selected cases of chronic gonorrhea with systemic manifestations.

Penicillin given parentally is the sheet-anchor of therapy even today. For acute gonorrhea aqueous procaine penicillin G (APPG) in doses of 2.4 or 4.8 mega units given intramuscularly at multiple sites in a single session, preceded by probenecid 1g orally is generally effective.

For those cases in whom penicillin is to be avoided, the alternate drugs are:

1. Ampicillin or amoxicillin 3g orally as a single dose preceded by probenecid 1g orally, or
2. Cotrimoxazole, 4g in a single dose.

Tetracycline 0.5g for times a day is given for at least five days is useful in those who are allergic to penicillin and its derivatives. For resistant strains, spectinomycin given in a single dose of 2g intramuscularly is an effective drug.

Treatment of complicated gonorrhea: Such patients require hospitalization and treatment. APPG 4.8 mega units with probenecid 1g orally followed by ampicillin 0.5g four times a day for 10 days are used. Aqueous crystalline penicillin given intravenously in a dose of 10 to 20 mega units total is also effective if given for a few days.

Pelvic inflammatory disease may demand further courses of ampicillin. Disseminated gonococcal infection are treated with high dose regimens using ampicillin 3.5g or amoxicillin 3g initially with probenecid 1g and followed by the same drug 0.5g four times a day for 10 days.

Arthritis with purulent joint effusion responds to systemic therapy. Local instillation of drugs and arthrotomy are not generally necessary.

Meningitis and endocarditis respond to very high doses of penicillin given intravenously, chloramphenicol is a useful alternative drug in subjects allergic to penicillin. Gonococcal ophthalmia should be treated with aqueous crystalline penicillin G, 50,000 units/Kg/day given intravenously in two doses at 12 hour intervals for 7 days.

It should be remembered that long-acting penicillins like benzathine penicillin have no place in the treatment of gonorrhea. When handling a case of gonorrhea, all sexual contacts should be traced and treated. Since several STDs may coexist, it is not rare to acquire syphilis along with the others. Hence all cases should be watched for the development of syphilis by appropriate tests.

Prophylactic treatment: Instillation of 1 to 2% silver nitrate solution into the eyes of newborn babies effectively prevents all forms of ophthalmia neonatorum whether it be of bacterial, viral or chlamydial origin.