Neisseria Gonorrhoeae:

Disease, Pathogenesis and

Prevention
Edward W. Hook III M.D.
Departments of Medicine, Epidemiology, and
Microbiology
Univ. of Alabama at Birmingham
And
Jefferson County Dept. of Health
Birmingham, Alabama

Edward W. Hook, III, M.D.

Grant/Research
Support:

NIH, CDC, WHO,

GlaxoSmithKline, Becton
Dickinson, Cepheid, GenProbe, Roche Molecular,
Cempra

Consultant:

MedHelp.org

Speakers Bureau:

None

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measures

Neisseria gonorrhoeae
Gram negative
intracellular diplococci
Obligate human pathogen
Many variable surface
structures
No broadly protective
immunity from reinfection

Syndromes Caused by Neisseria gonorrhoeae and

Chlamydia trachomatis

Males

Females

Neonates

Site

N. gonorrhoeae

C. trachomatis

Urethra

Urethritis

Urethritis

Epididymis

Epididymitis

Epididymitis

Systemic

Disseminated Gonococcal
Syndrome

Reiters
Syndrome

Cervix

Cervicitis

Cervicitis

Fallopian tube

Salpingitis/PID

Salpingitis/PID

Urethra

Urethritis

Urethral
Syndrome

Bartholins
Gland

Bartholin Abscess

Bartholin
Abscess

Eyes

Conjunctivitis

Conjunctivitis

Pharynx

Asymptomatic

Nasopharyngitis

Lungs

??

Pneumonia

C. Trachomatis and N. gonorrhoeae:

Biological Properties with Clinical Impact
C. trachomatis

N. gonorrhoeae

Growth

Living Cells

Artificial Media

Life Cycle

~36 hrs

~12-15 minutes

Inflammatory
Host Response

Mild

Brisk

Gonococcal Outer Membrane

TbpA,B

LbpA,B
Opa

Pili

attachment

LOS
serum
resistance

Rmp
blocking
antibodies

Porin
nutrient
channel

Iron
acquisition

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measures

STD Incidence
R = BcD
R=

Reproductive Rate

B=

Infectivity

C=

Sexual Partner Selection

Parameters (rate and variability)

D=

Duration of Infectivity

Anderson, RM and May RM; Nature 1988;333:323-320

STD Incidence Modifiers- GC

R = BcD
R=

Reproductive Rate

B=

Infectivity: GC biologic characteristics,

Condoms, (Vaccine)

C=

Sexual Partner Selection (rate and

variability) and Notification Parameters

D=

Duration of Infectivity: Expeditious Detection

of Infection and Effective Treatment

After Anderson, RM and May RM; Nature 1988;333:323-320

Changes In Gonorrhea Among MSM,

1992-1999 (GISP)*
Total

% MSM

1992

4858

4.5%

1999

4465

13.2%

* Fox et al, AJPH, 2001;91; 959-64.

Gonorrhea Age- and sex-specific rates:

United States, 2008
Men
750

Rate (per 100,000 population)

600

450

300

150

0
5.8

278.3
433.6
269.9
163.3
99.6
71.7
40.1
14.0
3.5
103.3

Age
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-54
55-64
65+
Total

Women
150

300

450

600

750

31.0
636.8
608.6
269.4
119.0
55.2
28.9
11.2
2.5
0.5
119.7

Gonorrhea Rates by state: United States and

outlying areas, 2008
48.3
12.7

7.3

22.4

32.7

58.4
12.5

108.7

47.1
23.7

84.7
70.5

82.3
18.0

77.3

56.9

89.0
160.9 138.2

81.9

136.3

71.2

143.3

146.5

107.2

Guam 62.8
54.4

88.7
169.4

41.2 134.0
176.3

142.6
159.2

214.2
256.8 210.5

170.5

220.2

47.5

6.0
7.6
33.0
29.0
80.0
61.0
120.8
118.6
451.5

Rate per 100,000

population

134.7

84.6

VT
NH
MA
RI
CT
NJ
DE
MD
DC

127.8

<=19.0
(n= 7)
19.1-100.0 (n= 24)
>100
(n= 23)

Puerto Rico 6.9

Virgin Is. 109.3

Note: The total rate of gonorrhea for the United States and outlying
areas (Guam, Puerto Rico, and Virgin Islands) was 110.3 per 100,000
population.

Gonorrhea Rates by race/ethnicity: United

States, 19972008
Rate (per 100,000 population)
900
720
American Indian/AK Native
Asian/Pacific Islander
Black
Hispanic
White

540
360
180
0
1999

2000

01

02

03

04

05

06

07

08

Features of US Gonorrhea
Epidemiology
Incidence in non-whites >30 times greater
than in whites
Urban residence
Lower socioeconomic status
Early coital debut
Single People
Past history of gonorrhea
Increasing focus on extra-genital
infections and antimicrobial resistance

HIV-1 RNA in Blood and Semen

of Urethritis Patients
RNA copies / ml (in thousands)

(median values)
140
120
100
80
60
40
20
0

Wk 1

Wk 3

Effect of STD Treatment on HIV-1 RNA in

Semen of Urethritis Patients
RNA copies / ml (in thousands)

(Cohen et al. Lancet 349: 1868-1873, 1997)

140
120
100
80
60
40
20
0

Wk1

Wk2

Wk3

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measures

Syndromes Caused by Neisseria gonorrhoeae and

Chlamydia trachomatis

Males

Females

Neonates

Site

N. gonorrhoeae

C. trachomatis

Urethra

Urethritis

Urethritis

Epididymis

Epididymitis

Epididymitis

Systemic

Disseminated Gonococcal
Syndrome

Reiters
Syndrome

Cervix

Cervicitis

Cervicitis

Fallopian tube

Salpingitis/PID

Salpingitis/PID

Urethra

Urethritis

Urethral
Syndrome

Bartholins
Gland

Bartholin Abscess

Bartholin
Abscess

Eyes

Conjunctivitis

Conjunctivitis

Pharynx

Asymptomatic

Nasopharyngitis

Lungs

??

Pneumonia

Urethritis in the Male

82% symptomatic within 2-5 days
Complications are rare
Colonization of the rectum 5%, pharynx 3-7%

Endocervical Gonococcal Infection

Symptoms within 10 days of infection: vaginal
discharge, dyspareunia, abnormal menstrual
bleeding
Examination: cervical discharge, erythema and
edema, mucosal friability, inflammation of
Bartholins glands
Associated with endocervical infection are
urethral (90%), rectal (40%), and pharyngeal
(10-20%) infection
Diagnosis confounded by C. trachomatis,
T. vaginalis, C. albicans, H. simplex and others

Salpingitis
Etiology
10-20% of patients with gonorrhea
Mixture of gonorrhea, chlamydia and strict
anaerobes
Lower abdominal pain, dyspareunia, abnormal
menstrual bleeding, abdominal complaints or
tenderness
Physical examination often revealing
Variable laboratory findings

STD Morbidity Considerations:

Males vs Females
Susceptibility To Infection
Efficiency Of Transmission
Probability Of Infection after Exposure
Probability Of Complication/Sequelae
Probability Of Symptomatic Infection
Specificity Of Symptoms

Disseminated Gonococcal
Infection

0.5-3% of patients with urethritis/cervicitis

Women > men: effects of menses
Dermatitis and tenosynovitis vs. arthritis
Proven (<50%), probable (80%) and
suspected DGI
Complement deficiency
Rare complications: endocarditis,
meningitis, osteomyelitis

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measures

Gonorrhea Diagnosis
Grams Stain
Culture
Antigen Detection
Nucleic Acid Detection
Nucleic Acid Amplification

Gonorrhea Diagnosis
Gram-Stain Performance
Men

Sensitivity

Specificity

Symptomatic Urethritis

90-95%

95-100%

Asymptomatic Urethral
Infection
Women

50-70%

95-100%

Cervicitis

50-70%

95-100%

Gonorrhea Diagnosis
Gram-Stain as a Prototypic Point of Care Test

Minutes to Availability of Results

Modest Equipment Requirements
Low Cost Reagents
High Sensitivity (Men)
High Specificity (Genital)

Changing Paradigms For Urogenital

Specimen Collection
Pre-NAATs: Specimen Quality Critical
- Endocervical Or Urethral Swabs
- Swab Order Impacts Test Results
: Culture > Non-Amplified Nucleic
Acid Detection > Antigen Detection
NAATs:

More Forgiving Specimen Collection

- Vaginal Swab > Endocervical Swab >
initial Void Urine

Impact of NAATs Testing for STDs

Alabama*
Cumulative Reported Infections as of:
Oct 1, 2005
(Pre-NAATs)
N. gonorrhoeae

6,698

C. trachomatis

11,638

*MMWR. Oct 6, 2006. pp:571-572.

Sept 30, 2006

(NAATs Testing)
7,110

(6% )

15,314 (32% )

Performance of NAATs for Diagnosis of

Pharyngeal and Rectal N. Gonorrhoeae
and C. trachomatis Infection
Performance Sites- Birmingham STD and HIV (2) Clinics
Chicago HIV Clinic
Testing

:Culture
:PCR (Roche Cobas Amplicor)
:Amplified Strand Displacement (Becton Dickinson ProbeTec)
:Transcription Mediated Amplification (Gen-Probe Aptima Combo 2)

Participants

: Testing based on self-reported exposure

: Women only Untreated genital infection or contact to infected
partner

Analyses

: Rotating standard Infection = 3 of 3 comparator tests positive

Performance of NAATs for Diagnosis of

Pharyngeal N. Gonorrhoeae and Infections
Pharyngeal Gonococcal Infections (N=961)
% Sensitivity (95%)

% Specificity (95% CI)

ProbeTec (SDA)

97.1 (85.1-99.9%)

94.2 (92.5-95.6%)

Amplicor (PCR)

91 (78.1-98.3%)

71.8 (68.7-74.6%)

Aptima Combo2 (TMA)

100 (89.7-100%)

96.2 (98.1-99.6%)

Culture

65.4 (50-78%)

99.0 (98.1-99.6%)

Bachmann, et al. J Clin Micro. 2009;47:902-907.

Performance of NAATs for Diagnosis of

Pharyngeal N. Gonorrhoeae and Infections
Pharyngeal Gonococcal Infection By Site
Site

No (%) Individuals

Genital and Oral

23 (28%)

Genital Only

28 (34.1%)

Oral Only

31 (37.8%)

Total Genital or Oral

82 (100%)

Bachman, et al. J Clin Micro. 2009; 47:902-907.

Performance of NAATs for Diagnosis of

Rectal N. Gonorrhoeae Infections
Rectal Gonococcal Infection
% Sensitivity (95% CI)

% Specificity (95% CI)

ProbeTec (SDA)

100% (85.2-100)

96% (93.4-97.8)

Amplicor (PCR)

95.8% (78.9-99.9)

96% (93.4-97.8)

Aptima Combo2 (TMA)

100% (85.2-100)

95.5% (92.7-97.4)

Culture

71.9% (53.3-86.3)

99.7% (98.4-100)

Bachmann, et al. J Clin Micro, 2010, 48: 1827-32

2010;48(5);1827-1832.

Performance of NAATs for Diagnosis

Rectal N. Gonorrhoeae Infections
Gonococcal Rectal or Genital Infections By Site
Site

No (%) Individuals

Genital and Rectal

12 (31.6%)

Genital Only

11 (28.9%)

Rectal Only

15 (39.5%)

Genital or Rectal

28 (100%)

Bachmann, et al.. J Clin Micro, 2010, 48: 1827-32 .

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measure

Emerging Gonococcal
Antimicrobial Resistance Deja Vu
Pre-1937

Antiseptic Irrigation With Potassium

Permanganate, Silver Salts,
Mercurochrome

1937

Sulfonamide Therapy

1943

Penicillin Therapy (Mahoney et al)

1944

35%Treatment Failure With Sulfonamides

1972

Penicillin Regimen Increased to 4.8 Million

Units Plus Probenecid

Emerging Gonococcal
Antimicrobial Resistance Deja Vu
1976 Recognition of PPNG (AFRICA, S.E. ASIA)
1984 High Level Chromosomal Penicillin Resistance,
(Durham, N.C.)
1985 Recognition of Plasmid Mediated Tetracycline
Resistance
1987 High Level Spectinomycin Resistance, (Korea)
1989 Penicillin No Longer Drug of Choice for G.C.
2002 Concern Regarding Rising Quinolone MICs

2006 CDC STD TREATMENT GUIDELINES

Uncomplicated Gonorrhea
Ceftriaxone 125 mg IM
or
Cefixime 400 mg PO
or
Ciprofloxacin 500 mg PO*
or
Ofloxacin 400 mg PO*
or
Levofloxacin 250 mg PO*
Plus, IF CHLAMYDIAL INFECTION IS NOT RULED
OUT
Azithromycin 1.0 g Single Dose Or Doxycycline
100 BID x 7d
* Not MSM or Travelers

Gonococcal Isolate Surveillance Project (GISP)

Drugs used to treat
gonorrhea in GISP patients, 19882008
100

Other

Tetracyclines
Penicillins

Ofloxacin

80

Ciprofloxacin
60

Cefixime
40

20

Ceftriaxone 250 mg

Spectinomycin

0
1988

Ceftriaxone 125 mg
Other Cephalosporins

1990

1992

1994

1996

1998

2000

2002

2004

Note: For 2008, Other includes no therapy (1.3%), azithromycin 2 g

(1.2%), levofloxacin (0.02%), and other less frequently used drugs.

2006

2008

Gonococcal Isolate Surveillance Project (GISP) Penicillin, tetracycline, and

ciprofloxacin resistance among GISP isolates, 2008

Note: PenR=penicillinase producing N. gonorrhoeae and chromosomally mediated penicillin-resistant N.

gonorrhoeae; TetR=chromosomally and plasmid mediated tetracycline-resistant N. gonorrhoeae;
QRNG=ciprofloxacin resistant N. gonorrhoeae.

Gonococcal Isolate Surveillance Project (GISP) Percent of

Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 19902008
Percent
16
Resistance
Intermediate resistance

12

0
1990

91

92

93

94

95

96

97

98

99 2000

01

02

03

04

05

06

Note: Resistant isolates have ciprofloxacin MICs 1 g/ml. Isolates with

intermediate resistance have ciprofloxacin MICs of 0.125 - 0.5 g/ml.
Susceptibility to ciprofloxacin was first measured in GISP in 1990.

07

08

Gonococcal Isolate Surveillance Project (GISP) Percent of

Neisseria gonorrhoeae isolates with resistance to
ciprofloxacin by sexual behavior,
20012006

Percent Ciprofloxacin Resistant

40
32

Heterosexual men
Men who have sex with men (MSM)

24
16
8
0
2001

2002

2003

2004

2005

2006

Percentage of GISP isolates resistant to ciprofloxacin*

Emergence of Fluoroquinolone-Resistant
N. gonorrhoeae (QRNG) in the US, 19892007

MSM

Hawaii
California

* Resistance to ciprofloxacin defined as MIC 1 g/ml

Note: MSM = Men who have sex with men; MSW = Men who exclusively have sex with women

MSW
(in rest of U.S.)

2006 CDC STD TREATMENT GUIDELINES

Uncomplicated Gonorrhea
Ceftriaxone 125 mg IM
or
Cefixime 400 mg PO
or
Ciprofloxacin 500 mg PO
or
Ofloxacin 400 mg PO
or
Levofloxacin 250 mg PO
Plus, IF CHLAMYDIAL INFECTION IS NOT RULED
OUT Azithromycin 1.0 g Single Dose Or Doxycycline
100 BID x 7d

2010 CDC STD TREATMENT

GUIDELINES
Uncomplicated Gonorrhea

Ceftriaxone 250 mg IM
or
Cefixime 400 mg PO
PLUS
Azithromycin 1.0 g Single Dose or
Doxycycline 100 BID x 7d

GONORRHEA THERAPY HISTORICAL PERSPECTIVE

Previously Recommended Medications For Gonorrhea Therapy

Sulfonamides

Penicillins

Macrolides
Tetracyclines
Aminoglycosides

Spectinomycin
Fluroquinolones

Decreased Cephalosporin Susceptibility

1999

Japan: 0% isolates have MICs to cefixime 0.5 g/ml

2001

Japan: Possible treatment failure with cefdinir

2002

Japan: 30% isolates have MICs to cefixime 0.5 g/ml

2003

Japan: 8 (12%) of men with GC in study unsuccessfully

treated with cefixime

2007

Hong Kong: 4 treatment failures with cefixime

2008-2009
2010

Increasing MICs to cephalosporins reported in Australia,

Europe, and US
Japan: isolate with Ceftriaxone MIC of 2 g/ml (female CSW)
Norway: 2 treatment failures with cefixime
Sweden: 1 pharyngeal GC treatment failure with
ceftriaxone 250 mg

Proportion of Isolates with

MICs to Cefixime 0.25 g/ml
n=52,785

1.4%
Percentage of isolates

Gonococcal Isolate Surveillance Project (GISP)

* p trend < 0.05
Preliminary data

(n=77)

Proportion of isolates with

MICs to Cefixime 0.25 g/ml
by Region
3.3%
(n=68)

n=52,785
Percentage of isolates

* p trend < 0.05

Preliminary data

Gonococcal Isolate Surveillance Project

(GISP)

Proportion of Isolates with MICs to Cefixime

0.25 g/ml by Sex of Sex Partner
n=50,873

Percentage of isolates

3.9%
(n=64)

Gonococcal Isolate Surveillance Project (GISP)

* p trend < 0.05
Note: MSM = Men who have sex with men; MSW = Men who exclusively have sex with women; Preliminary data

"Those who cannot remember

the past are condemned to
repeat it."
George Santayana

Reasons for STD Treatment Failure

Reinfection
Wrong Therapy
Wrong diagnosis
Wrong dosage/duration
Self medication
Resistant Organisms
Other

Neisseria Gonorrhoeae
Lecture Overview
The Organism
Epidemiology
Clinical Syndromes
Diagnosis
Treatment/Antimicrobial Resistance
Control Measures

Gonorrhea Prevention
Current:
Expeditious Diagnosis and Therapy
Behavior Change
Condoms
Antimicrobial Prophylaxis
Future:
Vaccines
Microbicides

Mucosal Immunity-How Different?

General belief:
Systemic and mucosal immune systems
are connected but separate.
Parenteral vaccination produces minimal
mucosal response, and many effective
vaccines do not prevent local colonization
sIgA are main Abs at mucosal surfaces
Abs necessary to block colonization?

Mucosal Defenses
Surface composition:
- mucous layer
- stratified squamous vs columnar
- normal flora, lactobacilli and H2O2
- [pH]
- lactoferrin
-cationic proteins (Defensins)
Antibodies, Complement, Immunocytes

Gonococcal Outer Membrane

TbpA,B

LbpA,B
Opa

Pili

attachment

LOS
serum
resistance

Rmp
blocking
antibodies

Porin
nutrient
channel

Iron
acquisition

Potential Gonococcal Vaccine

Strategies
Successful vaccine must induce a broadly crossreactive mucosal antibody response
Block attachment
Facilitate PMN uptake and bactericidal activity
Stimulate complement-mediated lysis
Delivery approaches
Live attenuated vaccine
Killed whole bacterial vaccine
Outer membrane vesicles
Purified protein subunit(s)
DNA vaccines
Mucosal immunization

Gonococcal
porin

Porin serotyping
antibodies identify
>40 different
serovars

Gonococcal Porin as a
Vaccine Candidate
Stably expressed by all gonococci
Less variability than Opa proteins or Pili
Anti-Por antibodies are bactericidal and opsonic
in vitro
Antibodies can be found in sera and genital
secretions following natural infection
Studies in women suggest Por-specific immunity
may exist
ButA Porin Vaccine Failed (Buchanan)

Photomicrographs from Swanson et al.and Novotny, et al.

Gonococcal Pilin as a
Vaccine Candidate
Pilus expression correlated with gonococcal
pathogenesis
Anti-pilus antibodies block bacterial
attachment to host cells in vitro
Antibodies can be found in sera and genital
secretions following natural infection
But...A Pilin Vaccine Failed (Brinton, Tramont)

Is A Gonococcal Vaccine Possible:

The Good News
GC infection may lead to some serotype
specific immunity (Plummer)
A Pil vaccine offered partial serotype
specific protection from mucosal challenge
(Brinton)
Urethral antibodies can be measured after
parenteral immunization (Brinton,Tramont)

Is a Gonococcal Vaccine Possible?

The Bad News
Natural Infection does not induce
significant antibody levels at mucosal sites
(Hedges et al)
Gonococcal Opa proteins are
immunosuppresive (Boulton et al)
Natural and experimental reinfection with
isogenic organisms is observed (Hobbs,
Deal)

Rationale for Human Experimentation

N. gonorrhoeae is strictly limited to human
hosts in nature.
Animal models have been unsuccessful or
impractical and expensive.
Experimental gonorrhea in men has
proven safe and free of complications.

Experimental Infection Protocol

Male subjects (18 35 years old) are recruited locally by IRB-approved
printed ads. Lab tests, physical exam and preliminary written informed
consent are obtained prior to trial.
Subjects are admitted to the Inpatient Unit of the General Clinical
Research Center at UNC Hospitals for 5 day trial; final written informed
consent obtained.
Approximately 240 L of PBS containing
104 106 gonococci is instilled into the
urethra with sterile #8 French pediatric catheter.
Subjects examined daily for signs or symptoms of urethritis, treated if
they experience any discomfort, or prior to discharge from the GCRC,
infected or not.
Subjects return for test of cure within one week and are paid $500.00.

Typical Course of Experimental

Gonococcal Infection
600

500

10000
400

1000

300

200

100
100

10

0
0

Time after inoculation (days)

Pyuria
(wbc x 104/ml urine sediment)

Bacteruria
(cfu/ml urine sediment)

100000

Summary and Concluding Remarks

A gonococcal vaccine is still needed
We know more now than we did when previous
vaccine failures were designed and tested
Novel vaccine delivery vehicles to stimulate cellmediated as well as humoral immunity are being
developed
Hope and enthusiasm remain high

References
Centers For Disease Control and Prevention,
Sexually Transmitted Disease Surveillance 2010,
Atlanta, GA: U.S. Department of Health and Human
Services, November 2011 (also @
http://www.cdc.gov/std/stats/
Centers For Disease Control and Prevention,
Sexually Transmitted Diseases Treatment
Guidelines, 2010. MMWR 2010; 55; 1-109.
Bolan G, Sparling PF, Wasserheit JN. The Emerging
Threat of Untreatable Gonococcal Infection. NEJM
2012: 366: 485-7.