The outcome of oropharyngeal gonorrhoea treatment with different regimens

Thyroglossal Duct Cyst Infection Caused by Neisseria gonorrhoeae: An Unusual Complication of Pharyngeal Gonorrhea

ABSTRACT

Neisseria gonorrhoeae is a human obligate pathogen whose clinical expression of disease ranges from localized genital infection to involvement of extragenital sites such as the conjunctiva and throat. We describe the second case of a thyroglossal duct abscess due to N. gonorrhoeae, an uncommon complication of pharyngeal gonococcal infection. The fortuitous occurrence in the same individual of these 2 conditions that both exhibit an occult clinical presentation likely accounts for rarity of this infection. We discuss the pertinent gonococcal and host factors that underlie the clinical manifestations of this infection. A particular focus is the fundamental role that the binding of the gonococcal opacity-associated protein to the ubiquitous human carcinoembryonic cell adhesion molecule plays in the pathogenesis of pharyngeal gonorrhea.

Management of Neisseria gonorrhoeae in the United States: Summary of Evidence From the Development of the 2020 Gonorrhea Treatment Recommendations and the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Treatment Guidelines

INTRODUCTION

Neisseria gonorrhoeae has developed resistance to all first-line recommended therapies, making gonococcal antimicrobial resistance a major public health concern given limited antibiotic options currently and an even smaller antimicrobial development pipeline. Since the release of the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines, azithromycin, part of the 2015 dual-drug treatment regimen, has had a rapid rise in resistance. The 2020 CDC Gonorrhea Treatment Recommendations and the 2021 Sexually Transmitted Infections (STI) Treatment Guidelines were developed weighing the priorities of treating the individual, protecting the population, and preventing antimicrobial resistance.

METHODS

Gonorrhea subject matter experts (SME) generated 8 key questions and conducted a literature review of updated data from 2013 to 2019 on gonorrhea antimicrobial resistance, treatment failures, clinical trials, and other key topics. More than 2200 abstracts were assessed, and 248 clinically relevant articles were thoroughly reviewed. SMEs also evaluated N gonorrhoeae antimicrobial resistance data from the Gonococcal Isolate Surveillance Project (GISP).

EVIDENCE

Although there have been reports of ceftriaxone treatment failures internationally, GISP data suggest that ceftriaxone minimal inhibitory concentrations (MICs) have remained stable in the United States, with < 0.1% exhibiting an "alert value" MIC (> 0.25 mcg/mL). However, GISP documented a rapid rise in the proportion of isolates with an elevated MIC (≥ 2.0 mcg/mL) to azithromycin-nearly 5% in 2018. At the same time, new pharmacokinetic/pharmacodynamic data are available, and there is greater recognition of the need for antimicrobial stewardship.

SUMMARY

The 2021 CDC STI Treatment Guidelines now recommend 500mg ceftriaxone intramuscularly once for the treatment of uncomplicated gonorrhea at all anatomic sites. If coinfection with chlamydia has not been excluded, cotreatment with doxycycline 100mg twice daily for 7 days should be added. Few alternative therapies exist for persons with cephalosporin allergies; there are no recommended alternative therapies for N gonorrhoeae infection of the throat.

What Is the Optimal Testing Strategy for Oropharyngeal Neisseria gonorrhoeae in Men Who Have Sex With Men? Comparing Selective Testing Versus Routine Universal Testing From Dutch Sexually Transmitted Infection Clinic Data (2008-2017)

BACKGROUND

Most oropharyngeal Neisseria gonorrhoeae infections are asymptomatic, and many infections remain undetected, creating a reservoir for ongoing transmission and potential drug resistance. It is unclear what the optimal testing policy is in men who have sex with men (MSM), as routine universal testing data are lacking.

METHODS

Surveillance data from all Dutch sexually transmitted infection (STI) clinics between 2008 and 2017 were used (N = 271 242 consultations). Oropharyngeal testing policy was defined as routine universal testing when ≥85% of consultations included oropharyngeal testing or as selective testing (<85% tested). Independent risk factors for oropharyngeal N. gonorrhoeae were assessed among MSM routinely universally screened using backward multivariable logistic regression analyses.

RESULTS

Routine universal testing was performed in 90% (238 619/265 127) of consultations. Prevalence was higher using routine universal testing (5.5%; 95% CI, 5.4-5.6; 12 769/233 476) than with selective testing (4.7%; 95% CI, 4.4-5.0; 799/17 079; P < .001). Proportions of oropharyngeal-only infections were 55% and 47%, respectively. Independent risk factors were age <31 years (OR, 2.1; 95% CI, 1.9-2.3), age 31-43 years (OR, 1.7; 95% CI, 1.6-1.9, compared with >43 years), being notified for any STI (OR, 2.0; 95% CI, 1.9-2.1), concurrent urogenital N. gonorrhoeae (OR, 2.4; 95% CI, 2.1-2.7), and concurrent anorectal N. gonorrhoeae (OR, 11.4; 95% CI, 10.6-12.3). When using any of the risk factors age, notified, or oral sex as testing indicators, 98.4% (81 022/82 332) of MSM would be tested, finding 99.5% (4814/4838) of infections.

CONCLUSIONS

Routine universal testing detected more oropharyngeal N. gonorrhoeae infections than selective testing, of which more than half would be oropharyngeal only. Using independent risk factors as testing indicator is not specific. Therefore, routine universal oropharyngeal testing in MSM is feasible and warranted, as currently advised in most guidelines.

Antibacterial mouthwash to prevent sexually transmitted infections in men who have sex with men taking HIV pre-exposure prophylaxis (PReGo): a randomised, placebo-controlled, crossover trial

BACKGROUND

Bacterial sexually transmitted infections (STIs) are highly prevalent among men who have sex with men who use HIV pre-exposure prophylaxis (PrEP), which leads to antimicrobial consumption linked to the emergence of antimicrobial resistance. We aimed to assess use of an antiseptic mouthwash as an antibiotic sparing approach to prevent STIs.

METHODS

We invited people using PrEP who had an STI in the past 24 months to participate in this single-centre, randomised, double-blind, placebo-controlled, AB/BA crossover superiority trial at the Institute of Tropical Medicine in Antwerp, Belgium. Using block randomisation (block size eight), participants were assigned (1:1) to first receive Listerine Cool Mint or a placebo mouthwash. They were required to use the study mouthwashes daily and before and after sex for 3 months each and to ask their sexual partners to use the mouthwash before and after sex. Participants were screened every 3 months for syphilis, chlamydia, and gonorrhoea at the oropharynx, anorectum, and urethra. The primary outcome was combined incidence of these STIs during each 3-month period, assessed in the intention-to-treat population, which included all participants who completed at least the first 3-month period. Safety was assessed as a secondary outcome. This trial is registered with Clinicaltrials.gov, NCT03881007.

FINDINGS

Between April 2, 2019, and March 13, 2020, 343 participants were enrolled: 172 in the Listerine followed by placebo (Listerine-placebo) group and 171 in the placebo followed by Listerine (placebo-Listerine) group. The trial was terminated prematurely because of the COVID-19 pandemic. 151 participants completed the entire study, and 89 completed only the first 3-month period. 31 participants withdrew consent, ten were lost to follow-up, and one acquired HIV. In the Listerine-placebo group, the STI incidence rate was 140·4 per 100 person-years during the Listerine period, and 102·6 per 100 person-years during the placebo period. In the placebo-Listerine arm, the STI incidence rate was 133·9 per 100 person-years during the placebo period, and 147·5 per 100 person-years during the Listerine period. We did not find that Listerine significantly reduced STI incidence (IRR 1·17, 95% CI 0·84-1·64). Numbers of adverse events were not significantly higher than at baseline and were similar while using Listerine and placebo. Four serious adverse events (one HIV-infection, one severe depression, one Ludwig's angina, and one testicular carcinoma) were not considered to be related to use of mouthwash.

INTERPRETATION

Our findings do not support the use of Listerine Cool Mint as a way to prevent STI acquisition among high-risk populations.

FUNDING

Belgian Research Foundation - Flanders (FWO 121·00).

Anti-Virulence Therapeutic Approaches for Neisseria gonorrhoeae

While antimicrobial resistance (AMR) is seen in both Neisseria gonorrhoeae and Neisseria meningitidis, the former has become resistant to commonly available over-the-counter antibiotic treatments. It is imperative then to develop new therapies that combat current AMR isolates whilst also circumventing the pathways leading to the development of AMR. This review highlights the growing research interest in developing anti-virulence therapies (AVTs) which are directed towards inhibiting virulence factors to prevent infection. By targeting virulence factors that are not essential for gonococcal survival, it is hypothesized that this will impart a smaller selective pressure for the emergence of resistance in the pathogen and in the microbiome, thus avoiding AMR development to the anti-infective. This review summates the current basis of numerous anti-virulence strategies being explored for N. gonorrhoeae.

An open-label, parallel-group, randomised controlled trial of antiseptic mouthwash versus antibiotics for oropharyngeal gonorrhoea treatment (OMEGA2)

New treatments for oropharyngeal gonorrhoea are required to address rising antimicrobial resistance. We aimed to examine the efficacy of a 14-day course of mouthwash twice daily compared to standard treatment (antibiotic) for the treatment of oropharyngeal gonorrhoea. The OMEGA2 trial was a parallel-group and open-labelled randomised controlled trial among men with untreated oropharyngeal gonorrhoea that was conducted between September 2018 and February 2020 at Melbourne Sexual Health Centre in Australia. Men were randomised to the intervention (rinsing, gargling and spraying mouthwash twice daily for 14 days) or control (standard treatment) arm and followed for 28 days. Participants in both arms were advised to abstain from sex and kissing with anyone for 14 days after enrolment. Oropharyngeal swabs were collected at baseline, Day 14 and Day 28 and tested for Neisseria gonorrhoeae by nucleic acid amplification test (NAAT) and culture. The primary outcome was the detection of oropharyngeal N. gonorrhoeae by NAAT at Day 14 after treatment. This trial was registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12618001380280). This trial stopped early due to a high failure rate in the mouthwash arm. Twelve men were randomly assigned to either mouthwash (n = 6) or standard treatment (n = 6). Of the 11 men who returned at Day 14, the cure rate for oropharyngeal gonorrhoea in the mouthwash arm was 20% (95% CI 1-72%; 1/5) and in the standard treatment arm was 100% (95% CI 54-100%; 6/6). A 14-day course of mouthwash failed to cure a high proportion of oropharyngeal gonorrhoea cases.

Single-Dose Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea

BACKGROUND

Antibiotic-resistant Neisseria gonorrhoeae has prompted the development of new therapies. Zoliflodacin is a new antibiotic that inhibits DNA biosynthesis. In this multicenter, phase 2 trial, zoliflodacin was evaluated for the treatment of uncomplicated gonorrhea.

METHODS

We randomly assigned eligible men and women who had signs or symptoms of uncomplicated urogenital gonorrhea or untreated urogenital gonorrhea or who had had sexual contact in the preceding 14 days with a person who had gonorrhea to receive a single oral dose of zoliflodacin (2 g or 3 g) or a single 500-mg intramuscular dose of ceftriaxone in a ratio of approximately 70:70:40. A test of cure occurred within 6±2 days after treatment, followed by a safety visit 31±2 days after treatment. The primary efficacy outcome measure was the proportion of urogenital microbiologic cure in the microbiologic intention-to-treat (micro-ITT) population.

RESULTS

From November 2014 through December 2015, a total of 179 participants (167 men and 12 women) were enrolled. Among the 141 participants in the micro-ITT population who could be evaluated, microbiologic cure at urogenital sites was documented in 55 of 57 (96%) who received 2 g of zoliflodacin, 54 of 56 (96%) who received 3 g of zoliflodacin, and 28 of 28 (100%) who received ceftriaxone. All rectal infections were cured in all 5 participants who received 2 g of zoliflodacin and all 7 who received 3 g, and in all 3 participants in the group that received ceftriaxone. Pharyngeal infections were cured in 4 of 8 participants (50%), 9 of 11 participants (82%), and 4 of 4 participants (100%) in the groups that received 2 g of zoliflodacin, 3 g of zoliflodacin, and ceftriaxone, respectively. A total of 84 adverse events were reported: 24 in the group that received 2 g of zoliflodacin, 37 in the group that received 3 g of zoliflodacin, and 23 in the group that received ceftriaxone. According to investigators, a total of 21 adverse events were thought to be related to zoliflodacin, and most such events were gastrointestinal.

CONCLUSIONS

The majority of uncomplicated urogenital and rectal gonococcal infections were successfully treated with oral zoliflodacin, but this agent was less efficacious in the treatment of pharyngeal infections. (Funded by the National Institutes of Health and Entasis Therapeutics; ClinicalTrials.gov number, NCT02257918 .).

Sexually transmitted infections: Need for extragenital screening

Extragenital infections can occur concurrently with simultaneous urogenital infections. Extragenital sites are believed to serve as hidden reservoirs and play a critical role in their transmission. The etiological relationship of the most widespread Sexually transmitted diseases (STD) pathogen to reproductive tract has long been established, but the distribution to extragenital sites appears to be infrequent and its correlation with the sexual practice still requires to be investigated. Optimal-screening strategies for extragenital infections are largely unknown. However, there is a lack of data on clinical outcomes and optimal treatment regimens for rectal and pharyngeal extragenital infections. Further studies are needed in settings other than reproductive health and STD clinics, especially in primary care clinics and resource-limited settings.

A Case of Persistent and Possibly Treatment Resistant Pharyngeal Gonorrhea

An HIV-negative man with pharyngeal gonorrhea had a positive test-of-cure (nucleic acid amplification test) result 7 days after treatment with ceftriaxone/azithromycin. Neisseria gonorrhoeae Multi-Antigen Sequencing Type 1407 and mosaic pen A (XXXIV) gene were identified in the test-of-cure specimen, and culture was negative. Retreatment with ceftriaxone 500 mg intramuscularly plus azithromycin 2 g orally yielded a negative test-of-cure result.

Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature

In the United States, sexually transmitted diseases due to Chlamydia trachomatis and Neisseria gonorrhoeae continue to be a major public health burden. Screening of extragenital sites including the oropharynx and rectum is an emerging practice based on recent studies highlighting the prevalence of infection at these sites. We reviewed studies reporting the prevalence of extragenital infections in women, men who have sex with men (MSM), and men who have sex only with women (MSW), including distribution by anatomical site. Among women, prevalence was found to be 0.6–35.8% for rectal gonorrhea (median reported prevalence 1.9%), 0–29.6% for pharyngeal gonorrhea (median 2.1%), 2.0–77.3% for rectal chlamydia (median 8.7%), and 0.2–3.2% for pharyngeal chlamydia (median 1.7%). Among MSM, prevalence was found to be 0.2–24.0% for rectal gonorrhea (median 5.9%), 0.5–16.5% for pharyngeal gonorrhea (median 4.6%), 2.1–23.0% for rectal chlamydia (median 8.9%), and 0–3.6% for pharyngeal chlamydia (median 1.7%). Among MSW, the prevalence was found to be 0–5.7% for rectal gonorrhea (median 3.4%), 0.4–15.5% for pharyngeal gonorrhea (median 2.2%), 0–11.8% for rectal chlamydia (median 7.7%), and 0–22.0% for pharyngeal chlamydia (median 1.6%). Extragenital infections are often asymptomatic and found in the absence of reported risk behaviors, such as receptive anal and oral intercourse. We discuss current clinical recommendations and future directions for research.

Gonorrhea Treatment Failures With Oral and Injectable Expanded Spectrum Cephalosporin Monotherapy vs Dual Therapy at 4 Canadian Sexually Transmitted Infection Clinics, 2010-2013

BACKGROUND

Antimicrobial resistance has developed to all antibiotics used to treat gonorrhea (GC), and trends in GC antimicrobial resistance have prompted changes in treatment guidelines. We examined treatment failures in sexually transmitted infection clinics.

METHODS

Four Canadian sexually transmitted infection clinics reviewed treatment regimens, minimum inhibitory concentrations for cephalosporins and azithromycin, anatomical infection sites, and treatment outcomes for GC infections between January 2010 and September 2013, in individuals who returned for test of cure within 30 days of treatment. Treatment failure was defined as the absence of reported sexual contact during the posttreatment period and (i) positive for Neisseria gonorrhoeae on culture of specimens taken at least 72 hours after treatment or (ii) positive nucleic acid amplification test specimens taken at least 2 to 3 weeks after treatment, and matching sequence type pretreatment and posttreatment. χ Test and Fisher exact test were used to assess association of categorical variables.

RESULTS

Of 389 specimens reviewed, GC treatment failures occurred in 13 specimens treated with cefixime 400-mg single dose (17.8% treatment failure rate regardless of anatomical site) and in 1 oropharyngeal specimen treated with cefixime 800-mg single dose. No treatment failures occurred using either ceftriaxone monotherapy or cefixime/ceftriaxone combined with azithromycin or doxycycline.

CONCLUSIONS

In contrast to oral cefixime monotherapy, no treatment failures were identified with injectable ceftriaxone monotherapy or combination GC treatment. Our data support the use of combination treatment of GC with an extended spectrum cephalosporin (including oral cefixime) with azithromycin or doxycycline as well as ceftriaxone monotherapy.

Will targeting oropharyngeal gonorrhoea delay the further emergence of drug-resistant Neisseria gonorrhoeae strains?

Gonorrhoea is an important sexually transmitted infection associated with serious complications and enhanced HIV transmission. Oropharyngeal infections are often asymptomatic and will only be detected by screening. Gonococcal culture has low sensitivity (<50%) for detecting oropharyngeal gonorrhoea, and, although not yet approved commercially, nucleic acid amplification tests (NAAT) are the assay of choice. Screening for oropharyngeal gonorrhoea should be performed in high-risk populations, such as men-who-have-sex-with-men(MSM). NAATs have a poor positive predictive value when used in low-prevalence populations. Gonococci have repeatedly thwarted gonorrhoea control efforts since the first antimicrobial agents were introduced. The oropharyngeal niche provides an enabling environment for horizontal transfer of genetic material from commensal Neisseria and other bacterial species to Neisseria gonorrhoeae. This has been the mechanism responsible for the generation of mosaic penA genes, which are responsible for most of the observed cases of resistance to extended-spectrum cephalosporins (ESC). As antimicrobial-resistant gonorrhoea is now an urgent public health threat, requiring improved antibiotic stewardship, laboratory-guided recycling of older antibiotics may help reduce ESC use. Future trials of antimicrobial agents for gonorrhoea should be powered to test their efficacy at the oropharynx as this is the anatomical site where treatment failure is most likely to occur. It remains to be determined whether a combination of frequent screening of high-risk individuals and/or laboratory-directed fluoroquinolone therapy of oropharyngeal gonorrhoea will delay the further emergence of drug-resistant N. gonorrhoeae strains.

[Sexually transmitted infections of the oral cavity]

Various sexual practices like fellatio, cunnilingus, or anilingus (rimming) can cause both symptomatic and asymptomatic oral infections in both sexes. Clinically apparent lesions are found in primary, secondary, and tertiary syphilis, in acute HIV infection and the subsequent stage of immunodeficiency (opportunistic infections), as well as in herpes and human papilloma virus infections. Genital candidiasis also can be transmitted to the oral cavity. Depending on the infective agent transmitted, ulcerative, inflammatory or papillomatous lesions of the lips, tongue, mucous membranes and pharynx occur. Oropharyngeal infections with Neisseria gonorrhoeae or Chlamydia trachomatis (Serovar D-K) can cause pharyngitis and tonsillitis with sore throat, but are completely asymptomatic in most cases. Asymptomatic infections are an important, but frequently overlooked reservoir for new infections. Systemic treatment of oral STI's usually is the same as that for anogenital infections. It can be accompanied by symptomatic topical therapy. When the tonsils and other difficult to reach tissues are infected, higher doses and an antibiotic with good tissue penetration are recommended.

Oropharyngeal gonorrhoea: rate of co-infection with sexually transmitted infection, antibiotic susceptibility and treatment outcome

The aim of the present study is to investigate the rate of co-infections with other sexually transmitted infections (STIs), antibiotic susceptibility and management of oropharyngeal gonorrhoea diagnosed in a busy genitourinary medicine clinic. The method involved a retrospective study on consecutive patients diagnosed with oropharyngeal gonorrhoea. A total of 131 patients were diagnosed with oropharyngeal gonorrhoea over the study period. The median age of the infected patients was 28 (interquartile range: 22 to 35) years. Forty-one (31%) of patients were younger than 24 years. High rates of co-infection with urethral gonorrhoea (37%), rectal gonorrhoea (37%) or chlamydial infection (16%) were identified. Thirty patients (23%) had only oropharyngeal infection. Twenty-two (17%) patients' isolates showed resistance to at least one antibiotic. Antibiotic resistance among oropharyngeal gonococcal isolates was above 5% between 2000 and 2009. Test-of-cure (TOC) was carried out for only 63 (48%) of patients; none had positive culture. Among 46 isolates treated with cefixime 400 mg/stat, 27 (59%) had TOC; all were negative. Repeat TOC was not carried out for any of the patients. In conclusion, successful management of oropharyngeal gonorrhoea should comprise of counselling, partner notification and TOC after treatment with appropriate antibiotic regimen.

The use of cephalosporins for gonorrhea: the impending problem of resistance

Gonorrhea remains an important clinical and public health problem throughout the world. Gonococcal infections have historically been diagnosed by Gram stain and culture but are increasingly diagnosed through nucleic acid tests, thereby eliminating the opportunity for antimicrobial susceptibility testing. Gonococcal infections are typically treated with single-dose therapy with an agent found to cure > 95% of cases. Unfortunately, the gonococcus has repeatedly developed resistance to antimicrobials including sulfonamides, penicillin, tetracyclines and fluoroquinolones. This has now left third-generation cephalosporins as the lone class of antimicrobials recommended as first-line therapy for gonorrhea in some regions. However, resistance to oral third-generation cephalosporins has emerged and spread in Asia, Australia and elsewhere. The mechanism of this resistance seems to be associated with a mosaic penicillin binding protein (penA) in addition to other chromosomal mutations previously found to confer resistance to beta-lactam antimicrobials (ponA, mtrR, penB, pilQ). Few good options exist or are in development for treating cephalosporin-resistant isolates, as most have had multidrug resistance. Preventing the spread of resistant isolates will depend on ambitious antimicrobial management programs, strengthening and expanding surveillance networks, and through effective sexually transmitted disease control and prevention.

The epidemiology of gonorrhea among men who have sex with men in Stockholm, Sweden, 1990-2004

OBJECTIVES

The objectives of this study were to analyze the spread of gonorrhea in men who have sex with men (MSM) in Stockholm regarding serovars, HIV status, and site of infection and to compare the distribution of serovars among HIV-positive and HIV-negative MSM.

STUDY DESIGN

Clinical and epidemiologic data were collected for all MSM diagnosed with gonorrhea in 1990 to 2004 at a clinic primarily serving MSM. Neisseria gonorrhoeae strains were serotyped.

RESULTS

A total of 1,039 isolates from 840 gonorrhea episodes in 721 patients were included. A sharp increase was seen during the 2000s. Ten percent of the cases were HIV-positive. The proportion of pharyngeal infections increased significantly (P <0.001) from 15% to 38% during the last 7 years. A great variation of serovars (n = 66) was observed, but only 5 were present >10 years. There was a significant difference (P = 0.001) in distribution of serovars correlated to HIV status.

CONCLUSION

Gonorrhea is a marker for HIV infection in MSM, but the increase in gonorrhea may be associated with genital-oral sexual practice rather than with high-risk sexual practice.

Prevalence and Incidence of Pharyngeal Gonorrhea in a Longitudinal Sample of Men Who Have Sex with Men: The EXPLORE Study

BACKGROUND

The prevalence of gonorrhea of the pharynx among select samples of men who have sex with men (MSM) ranges from 9% to 15%. To our knowledge, there have been no longitudinal studies in a prospective MSM cohort to estimate pharyngeal gonorrhea incidence or predictors of infection. We examined the prevalence, incidence, and sociodemographic and behavioral predictors of pharyngeal gonorrhea in a cohort of sexually active, human immunodeficiency virus-negative MSM.

METHODS

We conducted a prospective study of pharyngeal gonorrhea among MSM who were enrolled in a behavioral intervention study to prevent human immunodeficiency virus infection (Project EXPLORE). Participants were enrolled in this ancillary study from March 2001 through July 2003. At baseline and every 6 months thereafter until 31 July 2003, participants were tested for pharyngeal gonorrhea and were administered a questionnaire regarding their oral sex practices. Rectal and urethral gonorrhea testing were also performed.

RESULTS

Prevalence of pharyngeal gonorrhea was 5.5% (136 cases diagnosed from 2475 tests). The incidence rate was 11.2 cases per 100 person-years. Pharyngeal gonorrhea was positively associated with younger age and the number of insertive oral sex partners in the past 3 months. Ejaculation did not increase the risk of pharyngeal gonorrhea. Gonorrhea of the pharynx was asymptomatic in 92% of cases.

CONCLUSIONS

The pharynx is a common, asymptomatic reservoir for gonorrhea in sexually active MSM.

Multiple doses of cefodizime are necessary for the treatment of Neisseria gonorrhoeae pharyngeal infection

A single dose of cefodizime (CDZM), ceftriaxone (CTRX), or spectinomycin (SPCM) is recommended for the treatment of gonococcal urethritis or uterine cervicitis in the era of multidrug-resistant Neisseria gonorrhoeae; namely, cefozopran-resistant N. gonorrhoeae (CZRNG). N. gonorrhoeae pharyngeal infection is not so rare in Japan; however, the proper treatment regimen for this infection is not clear. We previously found that a single dose of CDZM completely eradicated multidrug-resistant N. gonorrhoeae in patients with urethritis and uterine cervicitis, so we tried a single 1.0-g dose of CDZM for the treatment of N. gonorrhoeae pharyngeal infection, including infections with CZRNG. The eradication rate of N. gonorrhoeae from the pharynx was 63.0% with a single 1.0-g dose of CDZM, while the rate for CZRNG with the same dose of CDZM was 38.5%. N. gonorrhoeae was completely eradicated from the pharynx when patients received one or two additional doses of CDZM. Therefore, we concluded that two to three doses of CDZM were necessary for the treatment of N. gonorrhoeae pharyngeal infection including infection with CZRNG.

Extragenital manifestations of Neisseria gonorrhoeae

Neisseria gonorrhoeae is a common cause of genitourinary sexually transmitted infections. N. gonorrhoeae is an obligate human pathogen that has evidence of tissue-specific host interactions and diverse extragenital manifestations of infection both in adult and pediatric populations. The clinical presentation of extragenital gonorrhea, diagnostic methods, treatment and preventive measures are reviewed.