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Is Tonsillectomy a Possible Treatment for IgA Nephropathy from Randomized Controlled Trial (RCT)? The first widespread use of serogroup C meningococcal conjugate vaccine (MenC) came in 1999 in the United Kingdom after a rise in serogroup C disease. The first quadrivalent conjugate meningococcal vaccine containing A, C, Y, and W polysaccharides conjugated to diphtheria toxoid was initially recommended for all children >11 years of age in the United States in 2005. A monovalent serogroup A vaccine, manufactured in India, was licensed in 2010 and rolled out to countries in the sub-Saharan African meningitis belt. Close (household and kissing) contacts of individuals with meningococcal disease are at increased risk (up to 1000 times the rate for the general population) of developing secondary disease; a secondary case follows as many as 3% of sporadic cases. The aim of prophylaxis is to eradicate colonization of close contacts with the strain that has caused invasive disease in the index case. In documented serogroup A, C, Y, or W disease, contacts may be offered immunization (preferably with a conjugate vaccine) in addition to chemoprophylaxis to provide protection beyond the duration of antibiotic therapy. Gonorrhea is a sexually transmitted infection (STI) of epithelium and commonly manifests as cervicitis, urethritis, proctitis, and conjunctivitis. The incidence of gonorrhea has declined significantly in the United States, but there were still ~311,000 newly reported cases in 2012. Gonorrhea predominantly affects young, nonwhite, unmarried, less educated members of urban populations. The incidence of gonorrhea is higher in developing countries than in industrialized nations. Gonorrhea is transmitted from males to females more efficiently than in the opposite direction. In any population, there exists a small minority of individuals who have high rates of new-partner acquisition.
The importance of humoral immunity in host defenses against neisserial infections is best illustrated by the predisposition of persons deficient in terminal complement components (C5 through C9) to recurrent bacteremic gonococcal infections and to recurrent meningococcal meningitis or meningococcemia. Gonococci become fully resistant to antibiotics either by chromosomal mutations or by acquisition of R factors (plasmids). Quinolone-containing regimens were also recommended for treatment of gonococcal infections; the fluoroquinolones offered the advantage of antichlamydial activity when administered for 7 days. Resistance to spectinomycin, which has been used in the past as an alternative agent, has been reported. The physical examination may reveal a mucopurulent discharge (mucopus) issuing from the cervical os. The most common form of gonorrhea in neonates is ophthalmia neonatorum, which results from exposure to infected cervical secretions during parturition. Menstruation is a risk factor for dissemination, and approximately two-thirds of cases of DGI are in women.
The clinical manifestations of DGI have sometimes been classified into two stages: a bacteremic stage, which is less common today, and a joint-localized stage with suppurative arthritis. Suppurative arthritis involves one or two joints, most often the knees, wrists, ankles, and elbows (in decreasing order of frequency); other joints occasionally are involved.
Gonococcal endocarditis, although rare today, was a relatively common complication of DGI in the preantibiotic era, accounting for about one-quarter of reported cases of endocarditis. A rapid diagnosis of gonococcal infection in men may be obtained by Gram’s staining of urethral exudates (Fig. PMNs are often seen in the endocervix on a Gram’s stain, and an abnormally increased number (?30 PMNs per field in five 1000? oil-immersion microscopic fields) establishes the presence of an inflammatory discharge.
Increasingly, nucleic acid probe tests are being substituted for culture for the direct detection of N. Because of the legal implications, the preferred method for the diagnosis of gonococcal infection in children is a standardized culture. Treatment failure can lead to continued transmission and the emergence of antibiotic resistance.
Currently, a single IM dose of the third-generation cephalosporin ceftriaxone is the mainstay of therapy for uncomplicated gonococcal infection of the urethra, cervix, rectum, or pharynx and almost always results in an effective cure.
Persons with uncomplicated infections who receive ceftriaxone do not need a test of cure; however, cultures for N. Gonococcal meningitis and endocarditis should be treated in the hospital with high-dose IV ceftriaxone (1–2 g every 12 h); therapy should continue for 10–14 days for meningitis and for at least 4 weeks for endocarditis. Condoms, if properly used, provide effective protection against the transmission and acquisition of gonorrhea as well as other infections that are transmitted to and from genital mucosal surfaces. Haemophilus influenzae was first recognized in 1892 by Pfeiffer, who erroneously concluded that the bacterium was the cause of influenza. The antigenically distinct type b capsule is a linear polymer composed of ribosyl-ribitol phosphate.
The widespread use of Hib conjugate vaccines in many industrialized countries has resulted in striking decreases in the rate of nasopharyngeal colonization by Hib and in the incidence of Hib infection (Fig. Hib strains cause systemic disease by invasion and hematogenous spread from the respiratory tract to distant sites such as the meninges, bones, and joints. Since nontypable strains lack a capsule, the immune response to infection is directed at noncapsular antigens.
Infection enters latent period – persists for many years without producing clinical symptoms.
This paper deals with a case of arthritis of the knee with adjacent osteomyelitis caused byMycobacterium terrae in a patient with rheumatoid arthritis; this confirms the pathogenicity of this organism. In diesem Artikel wird ein Fall von infektioser Arthritis des Kniegelenks mit angrenzender Osteomyelitis bei einem Patienten mit rheumatoider Arthritis beschrieben.
JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. Pneumonia The alveoli are tiny air sacs within the lungs where the exchange of oxygen and carbon dioxide takes place.
Bronchiole: A tiny tube in the air conduit system within the lungs that is a continuation of the bronchi and connects to the alveoli (the air sacs) where oxygen exchange occurs.
Diagnosis of Pneumonia Pneumonia usually produces distinctive sounds; these abnormal sounds are caused by narrowing of airways or filling of the normally air-filled parts of the lung with inflammatory cells and fluid, a process called consolidation. Diagnosis of Pneumonia In most cases, the diagnosis of pneumonia is confirmed with a chest x-ray. Since the organism was frequently isolated from the lungs of patients during the 1890 and 1918 influenza pandemics, scientists incorrectly concluded that the bacterium was the causative agent.
Bacterial Causes of Late Onset HAP Pseudomonas aeruginosa39-64% Acinetobacter spp.6-26% Enterobacteriaceae16-31% Methicillin-resistant S.
A mass vaccination campaign involving all individuals <19 years of age was undertaken, and the number of laboratory-confirmed serogroup C cases fell from 955 in 1998–1999 to just 29 in 2011–2012. There is strong evidence that this vaccine has been highly effective in controlling epidemic meningococcal disease in the region, with some evidence of a >90% reduction in disease in vaccinated populations. Other vaccine candidates have been identified since sequencing of the meningococcal genome. Prophylaxis should be given to all contacts at the same time to avoid recolonization by meningococci transmitted from untreated contacts and should also be used as soon as possible to treat early disease in secondary cases.
Mass vaccination has been used successfully to control disease during outbreaks in closed communities (educational and military establishments) as well as during epidemics in open communities. Exclusively a human pathogen, the gonococcus contains, on average, three genome copies per coccal unit; this polyploidy permits a high level of antigenic variation and the survival of the organism in its host. Gonorrhea remains a major public health problem worldwide, is a significant cause of morbidity in developing countries, and may play a role in enhancing transmission of HIV. The number of reported cases probably represents half of the true number of cases—a discrepancy resulting from underreporting, self-treatment, and nonspecific treatment without a laboratory-proven diagnosis.
The exact incidence of any STI is difficult to ascertain in developing countries because of limited surveillance and variable diagnostic criteria. The rate of transmission to a woman during a single unprotected sexual encounter with an infected man is ~50–70%.
These “core-group members” or “high-frequency transmitters” are vital in sustaining STI transmission at the population level.
Opa contributes to intergonococcal adhesion, which is responsible for the opaque nature of gonococcal colonies on translucent agar and the organism’s adherence to a variety of eukaryotic cells, including polymorphonuclear leukocytes (PMNs). Porin molecules exist as trimers that provide anion-transporting aqueous channels through the otherwise hydrophobic outer membrane. Transferrin-binding proteins (Tbp1 and Tbp2) and lactoferrin-binding protein are required for scavenging iron from transferrin and lactoferrin in vivo.
Activation of phosphatidylcholine-specific phospholipase C and acidic sphingomyelinase by N. Gonococcal porin induces T cell–proliferative responses in persons with urogenital gonococcal disease. Because this agent usually is not associated with resistance to other antibiotics, spectinomycin can be reserved for use against multidrug-resistant strains of N. The usual incubation period after exposure is 2–7 days, although the interval can be longer and some men remain asymptomatic.
The remaining men, who are largely asymptomatic, accumulate in number over time and constitute about two-thirds of all infected men at any point in time; together with men incubating the organism (who shed the organism but are asymptomatic), they serve as the source of spread of infection. Because Gram’s stain is not sensitive for the diagnosis of gonorrhea in women, specimens should be submitted for culture or a nonculture assay (see “Laboratory Diagnosis,” below).
The mode of acquisition is oral-genital sexual exposure, with fellatio being a more efficient means of transmission than cunnilingus. Recognition of gonorrhea early in pregnancy also identifies a population at risk for other STIs, particularly chlamydial infection, syphilis, and trichomoniasis.
Gonococcal vulvovaginitis is the most common manifestation of gonococcal infection in children beyond infancy. In the 1970s, DGI occurred in ~0.5–3% of persons with untreated gonococcal mucosal infection. Most patients who develop gonococcal septic arthritis do so without prior polyarthralgias or skin lesions; in the absence of symptomatic genital infection, this disease cannot be distinguished from septic arthritis caused by other pathogens. The nonulcerative STIs enhance the transmission of HIV by three- to fivefold; transmission of HIV-infected immune cells and increased viral shedding by persons with urethritis or cervicitis may contribute (Chap. Unfortunately, the presence or absence of gram-negative intracellular monococci or diplococci in cervical smears does not accurately predict which patients have gonorrhea, and the diagnosis in this setting should be made by culture or another suitable nonculture diagnostic method.
Two positive NAATs, each targeting a different nucleic acid sequence, may be substituted for culture of the cervix or the urethra as legal evidence of infection in children.
The importance of adequate treatment with a regimen that the patient will adhere to cannot be overemphasized.
Quinolone-containing regimens are no longer recommended in the United States as first-line treatment because of widespread resistance.
Persons who cannot tolerate ceftriaxone and those in whom quinolones are contraindicated may be treated with spectinomycin if it is available, but this agent results in a cure rate of ?52%.
Hospitalization is indicated if the diagnosis is uncertain, if the patient has localized joint disease that requires aspiration, or if the patient cannot be relied on to comply with treatment. All persons who experience more than one episode of DGI should be evaluated for complement deficiency. Spermicidal preparations used with a diaphragm or cervical sponges impregnated with nonoxynol 9 offer some protection against gonorrhea and chlamydial infection. The type b polysaccharide capsule is an important virulence factor affecting the bacterium’s ability to avoid opsonization and cause systemic disease.
The level of (maternally acquired) serum antibody to the capsular polysaccharide, which is a polymer of polyribitol ribose phosphate (PRP), declines from birth to 6 months of age and, in the absence of vaccination, remains low until ~2 or 3 years of age. These antigens have generated considerable interest as immune targets and potential vaccine components.
44) is a life-threatening Hib infection involving cellulitis of the epiglottis and supraglottic tissues.
Diese Infektion wurde durchMycobacterium terrae verursacht, womit die Pathogenitat dieser Organismen bestatigt wird. Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.
Bronchiole is the diminutive of bronchus, from the word bronchos by which the Greeks referred to the conduits to the lungs. For most bacterial pneumonias, the involved tissue of the lung appears on the x-ray as a dense white patch (because the x-ray beam does not get through), compared with nearby healthy lung tissue that appears black (because the x-rays get through easily, exposing the film). The effectiveness of the immunization program was attributed both to direct protection of immunized persons and to reduced transmission of the organism in the population as a result of decreased rates of colonization among the immunized (herd immunity). Outer-membrane vesicles (OMVs) containing outer-membrane proteins, phospholipid, and LPS can be extracted from cultures of N.


A combination vaccine that includes the New Zealand OMV vaccine and three recombinant proteins (neisserial adhesin A, factor H–binding protein, and neisserial heparin-binding antigen) is immunogenic in infancy and has been licensed for use in Europe and Australia.
The rate of secondary cases is highest during the week after presentation of the index case.
Disseminated gonococcemia is an uncommon event whose manifestations include skin lesions, tenosynovitis, arthritis, and (in rare cases) endocarditis or meningitis.
The number of reported new cases of gonorrhea in the United States rose from ~250,000 in the early 1960s to a high of 1.01 million in 1978.
Studies in Africa have clearly demonstrated that nonulcerative STIs such as gonorrhea (in addition to ulcerative STIs) are an independent risk factor for the transmission of HIV (Chap. Oropharyngeal gonorrhea occurs in ~20% of women who practice fellatio with infected partners. Another instrumental factor in sustaining gonorrhea in the population is the large number of infected individuals who are asymptomatic or have minor symptoms that are ignored. Pilus expression is rapidly switched off with unselected subculture because of rearrangements in pilus genes.
Certain Opa variants promote invasion of epithelial cells, and this effect has been linked with the ability of Opa to bind vitronectin, glycosaminoglycans, and several members of the carcinoembryonic antigen–related cell adhesion molecule (CEACAM) receptor family. Porin exhibits stable interstrain antigenic variation and forms the basis for gonococcal serotyping. Gonococcal LOS possesses marked endotoxic activity and contributes to the local cytotoxic effect in a fallopian tube model.
A significant increase in porin-specific interleukin (IL) 4–producing CD4+ as well as CD8+ T lymphocytes is seen in individuals with mucosal gonococcal disease. The first effective agents against gonorrhea were the sulfonamides, which were introduced in the 1930s and became ineffective within a decade. The first type, which is drug specific, is a single-step mutation leading to high-level resistance. The rising MICs of oral cefixime (the previously recommended alternative oral third-generation cephalosporin) against N.
However, the women who either remain asymptomatic or have only minor symptoms may delay in seeking medical attention.
Edematous and friable cervical ectopy and endocervical bleeding induced by gentle swabbing are more often seen in chlamydial infection. In certain female adolescent populations in the United States, pharyngeal gonorrhea has become as common as genital gonorrhea. As in genital infection, the manifestations range from severe to occasionally mild or asymptomatic disease. The risks of salpingitis and PID—conditions associated with a high rate of fetal loss—are highest during the first trimester. Anorectal and pharyngeal infections are common in these children and are frequently asymptomatic. The lower incidence of DGI at present is probably attributable to a decline in the prevalence of particular strains that are likely to disseminate. Complement deficiencies, especially of the components involved in the assembly of the membrane attack complex (C5 through C9), predispose to neisserial bacteremia, and persons with more than one episode of DGI should be screened with an assay for total hemolytic complement activity.
Patients in the bacteremic stage have higher temperatures, and chills more frequently accompany their fever. The detection of gram-negative intracellular monococci and diplococci is usually highly specific and sensitive in diagnosing gonococcal urethritis in symptomatic males but is only ~50% sensitive in diagnosing gonococcal cervicitis. A common assay uses a nonisotopic chemiluminescent DNA probe that hybridizes specifically with gonococcal 16S ribosomal RNA; this assay is as sensitive as conventional culture techniques. Thus highly effective single-dose regimens have been developed for uncomplicated gonococcal infections. Pregnant women with gonorrhea, who should not take doxycycline, should receive concurrent treatment with a macrolide antibiotic for possible chlamydial infection. Persons given an alternative regimen should return for a test of cure targeting the infected anatomic site.
Persons given spectinomycin should have a pharyngeal sample cultured 3–5 days after treatment as a test of cure. Ocular gonococcal infections in older children and adults should be managed with a single dose of ceftriaxone combined with saline irrigation of the conjunctivae (both undertaken expeditiously), and patients should undergo a careful ophthalmologic evaluation that includes a slit-lamp examination. However, the frequent use of preparations that contain nonoxynol 9 is associated with mucosal disruption that paradoxically may enhance the risk of HIV infection in the event of exposure. Its aerobic growth requires two factors: hemin (X factor) and nicotinamide adenine dinucleotide (V factor). In addition, some strains lack a polysaccharide capsule and are referred to as nontypable strains.
Adults with chronic bronchitis experience recurrent lower respiratory tract infection due to nontypable strains. The age at the antibody nadir correlates with that of the peak incidence of type b disease.
The human immune response to nontypable strains appears to be strain-specific, a characteristic that accounts in part for the propensity of these strains to cause recurrent otitis media and recurrent exacerbations of chronic bronchitis in immunocompetent hosts. The clinical manifestations of Hib meningitis are similar to those of meningitis caused by other bacterial pathogens. The organism requires a blood-containing medium for growth Influenzae: The bacterium often attacks the lungs of a patient with viral influenza. Data on immunogenicity and effectiveness have shown that the duration of protection is short when the vaccine is administered in early childhood; thus booster doses are needed to maintain population immunity. The risk falls rapidly but remains above baseline for up to 1 year after the index case; 30% of secondary cases occur in the first week, 20% in the second week, and most of the remainder over the next 6 weeks. Although rifampin has been most widely used and studied, it is not the optimal agent because it fails to eradicate carriage in 15–20% of cases, rates of adverse events have been high, compliance is affected by the need for four doses, and emerging resistance has been reported. They are distinguished from other neisseriae by their ability to grow on selective media and to use glucose but not maltose, sucrose, or lactose. The recorded incidence of gonorrhea in modern times peaked in 1975, with 468 reported new cases per 100,000 population in the United States. These persons, unlike symptomatic individuals, may not cease sexual activity and therefore continue to transmit the infection.
LOS core sugars undergo a high degree of phase variation under different conditions of growth; this variation reflects genetic regulation and expression of glycotransferase genes that dictate the carbohydrate structure of LOS. A portion of these lymphocytes that show a porin-specific TH2-type response could traffic to mucosal surfaces and play a role in immune protection against the disease. The second type involves mutations at several chromosomal loci that combine to determine the level as well as the pattern of resistance. QRNG is particularly common in the Pacific Islands (including Hawaii) and Asia, where, in certain areas, all gonococcal strains are now resistant to quinolones. Nevertheless, outbreaks caused by strains resistant to spectinomycin have been documented in Korea and England when the drug has been used for primary treatment of gonorrhea. Urethral discharge and dysuria, usually without urinary frequency or urgency, are the major symptoms.
Epididymitis is now an uncommon complication, and gonococcal prostatitis occurs rarely, if at all.
These minor symptoms may include scant vaginal discharge issuing from the inflamed cervix (without vaginitis or vaginosis per se) and dysuria (often without urgency or frequency) that may be associated with gonococcal urethritis.
Gonococcal infection may extend deep enough to produce dyspareunia and lower abdominal or back pain. Such women are usually asymptomatic but occasionally have acute proctitis manifested by anorectal pain or pruritus, tenesmus, purulent rectal discharge, and rectal bleeding. Most cases resolve spontaneously, and transmission from the pharynx to sexual contacts is rare. The variability in clinical manifestations may be attributable to differences in the ability of the infecting strain to elicit an inflammatory response. Pharyngeal infection, most often asymptomatic, may be more common during pregnancy because of altered sexual practices.
An initial nonspecific conjunctivitis with a serosanguineous discharge is followed by tense edema of the eyelids, chemosis, and a profuse, thick, purulent discharge. The urethra, Bartholin’s and Skene’s glands, and the upper genital tract are rarely involved. DGI strains resist the bactericidal action of human serum and generally do not incite inflammation at genital sites, probably because of limited generation of chemotactic factors. HIV has been detected by polymerase chain reaction (PCR) more commonly in ejaculates from HIV-positive men with gonococcal urethritis than in those from HIV-positive men with nongonococcal urethritis. If a history of rectal sex is elicited, a rectal wall swab (uncontaminated with feces) should be cultured. Food and Drug Administration for use with specimens obtained from the pharynx and rectum of infected children, NAATs from these sites are preferred for diagnostic evaluation in adult victims of suspected sexual abuse, especially if the NAATs have been evaluated by the local laboratory and found to be superior. Synovial fluid should be inoculated into blood culture broth medium and plated onto chocolate agar rather than selective medium because this fluid is not likely to be contaminated with commensal bacteria. The modified 2010 treatment guidelines for gonococcal infections from the Centers for Disease Control and Prevention (CDC) are summarized in Table 181-1.
A single 1-g dose of azithromycin, which is effective therapy for uncomplicated chlamydial infections, results in an unacceptably low cure rate (93%) for gonococcal infections and should not be used alone.
A single 2-g dose of azithromycin may be used in areas where rates of resistance to azithromycin are low. Nonsteroidal anti-inflammatory agents may be indicated to alleviate pain and hasten clinical improvement of affected joints. Type b and nontypable strains are the most relevant strains clinically (Table 182-1), although encapsulated strains other than type b can cause disease. Nontypable strains are primarily mucosal pathogens but occasionally cause invasive disease. Worldwide, invasive Hib disease occurs predominantly in unimmunized children and in those who have not completed the primary immunization series.
Antibody to PRP then appears partly as a result of exposure to Hib or cross-reacting antigens. Fever and altered central nervous system function are the most common features at presentation. Its unique epidemiologic features are its occurrence in an older age group (2–7 years old) than other Hib infections and its absence among Navajo Indians and Alaskan Eskimos. In contrast, immunity after a dose of vaccine given in adolescence appears to be prolonged. In outbreaks of meningococcal disease, mass prophylaxis has been used; however, limited data support population intervention, and significant concerns have arisen about adverse events and the development of resistance.
Ceftriaxone as a single IM or IV injection is highly (97%) effective in carriage eradication and can be used at all ages and in pregnancy.
This peak was attributable to the interaction of several variables, including improved accuracy of diagnosis, changes in patterns of contraceptive use, and changes in sexual behavior. This situation underscores the importance of contact tracing and empirical treatment of the sex partners of index cases. Piliated strains adhere better to cells derived from human mucosal surfaces and are more virulent in organ culture models and human inoculation experiments than nonpiliated variants. DGI strains are generally resistant to the killing action of normal human serum and do not incite a significant local inflammatory response; therefore, they may not cause symptoms at genital sites. Ceramide accumulation within cells leads to apoptosis, which may disrupt epithelial integrity and facilitate entry of gonococci into subepithelial tissue. Few data clearly indicate that protective immunity is acquired from a previous gonococcal infection, although bactericidal and opsonophagocytic antibodies to porin and LOS may offer partial protection. Penicillin, ampicillin, and tetracycline are no longer reliable for the treatment of gonorrhea and should not be used. The discharge initially is scant and mucoid but becomes profuse and purulent within a day or two.
Other unusual local complications of gonococcal urethritis include edema of the penis due to dorsal lymphangitis or thrombophlebitis, submucous inflammatory “soft” infiltration of the urethral wall, periurethral abscess or fistula, inflammation or abscess of Cowper’s gland, and seminal vesiculitis. Although the incubation period of gonorrhea is less well defined in women than in men, symptoms usually develop within 10 days of infection and are more acute and intense than those of chlamydial cervicitis. In such cases, it is imperative to consider a diagnosis of pelvic inflammatory disease (PID) and to administer treatment for that disease (Chaps. The intense inflammation of the vagina makes the physical (speculum and bimanual) examination extremely painful.
Among men who have sex with men (MSM), the frequency of gonococcal infection, including rectal infection, fell by ?90% throughout the United States in the early 1980s, but a resurgence of gonorrhea among MSM has been documented in several cities since the 1990s.


Infection may result in a markedly swollen eyelid, severe hyperemia and chemosis, and a profuse purulent discharge. Prolonged rupture of the membranes, premature delivery, chorioamnionitis, funisitis (infection of the umbilical cord stump), and sepsis in the infant (with N.
Corneal ulcerations that result in nebulae or perforation may lead to anterior synechiae, anterior staphyloma, panophthalmitis, and blindness.
All children with gonococcal infection should also be evaluated for chlamydial infection, syphilis, and possibly HIV infection. Strains recovered from DGI cases in the 1970s were often of the PorB.1A serotype, were highly susceptible to penicillin, and had special growth requirements—including arginine, hypoxanthine, and uracil—that made the organism more fastidious and more difficult to isolate. Polyarthralgias usually include the knees, elbows, and more distal joints; the axial skeleton is generally spared.
Part of the sample should be inoculated onto a plate of modified Thayer-Martin or other gonococcal selective medium for culture. A presumptive diagnosis of gonorrhea cannot be made on the basis of gram-negative diplococci in smears from the pharynx, where other Neisseria species are components of the normal flora. Cultures should be obtained from the pharynx and anus of both girls and boys, the urethra of boys, and the vagina of girls; cervical specimens are not recommended for prepubertal girls. Rising MICs of cefixime worldwide have led the CDC to discontinue its recommendation of this agent as first-line treatment for uncomplicated gonorrhea. A single 2-g dose of azithromycin, particularly in the extended-release microsphere formulation, delivers azithromycin to the lower gastrointestinal tract, thereby improving tolerability. If culture is not readily available and a NAAT is positive, every effort should be made to perform a confirmatory culture. Certain groups have a higher incidence of invasive Hib disease than the general population, including African-American children and Native American groups. Systemic Hib disease is unusual after the age of 6 years because of the presence of protective antibody. OMVs prepared in this way were used in efficacy trials with a Norwegian outbreak strain and reduced the incidence of group B disease among 14- to 16-year-old schoolchildren by 53%. The incidence of the disease has since declined gradually and is currently estimated at 120 cases per 100,000, a figure that is still the highest among industrialized countries. In a fallopian tube explant model, pili mediate gonococcal attachment to nonciliated columnar epithelial cells. This phenomenon may serve to explain the transient decrease in CD4+ T lymphocyte counts associated with gonococcal infection. These characteristics may be related to the ability of PorB.1A strains to bind to complement-inhibitory molecules, resulting in a diminished inflammatory response.
Release of chemotactic factors as a result of complement activation contributes to inflammation, as does the toxic effect of LOS in provoking the release of inflammatory cytokines.
On the other hand, women who are infected and acquire high levels of antibody to another outer-membrane protein, Rmp (reduction modifiable protein, formerly called protein III), may be especially likely to become reinfected with N. As recently as 2007, chromosomal mutations accounted for resistance to penicillin, tetracycline, or both in ~16% of strains surveyed in the United States. In the United States, QRNG has been identified in midwestern and eastern areas as well as in states on the Pacific coast, where resistant strains were first seen.
Gram’s staining of the urethral discharge may reveal PMNs and gram-negative intracellular monococci and diplococci (Fig.
The vaginal mucosa is red and edematous, and an abundant purulent discharge is often present. Gonococcal isolates from the rectum of MSM tend to be more resistant to antimicrobial agents than are gonococcal isolates from other sites.
Infections described at other mucosal sites in infants, including vaginitis, rhinitis, and anorectal infection, are likely to be asymptomatic. Skin lesions are seen in ~75% of patients and include papules and pustules, often with a hemorrhagic component (Fig. Not only does gonorrhea enhance the transmission of HIV, but it may also increase the individual’s risk for acquisition of HIV.
It is important to process all samples immediately because gonococci do not tolerate drying. Thus a culture-confirmatory test and formal antimicrobial susceptibility testing, if needed, cannot be performed. For boys with a urethral discharge, a meatal specimen of the discharge is adequate for culture.
The recommendations for uncomplicated gonorrhea apply to HIV-infected as well as HIV-uninfected patients. Azithromycin is effective against sensitive strains, but this drug is expensive, causes gastrointestinal distress, and is not recommended for routine or first-line treatment of gonorrhea. All positive cultures for test of cure should undergo antimicrobial susceptibility testing. Although this increased incidence has not yet been accounted for, several factors may be relevant, including age at exposure to the bacterium, socioeconomic conditions, and genetic differences. Nontypable strains that cause infection in adults with COPD differ in pathogenic potential and genome content from strains that cause otitis media. Vaccines in which PRP is conjugated to protein carrier molecules have been developed and are now used widely. Subdural effusion, the most common complication, is suspected when, despite 2 or 3 days of appropriate antibiotic therapy, the infant has seizures, hemiparesis, or continued obtundation. Vaccine Adverse Events Reporting System indicated that there might be a short-term increase in the risk of Guillain-Barre syndrome after immunization with the diphtheria conjugate vaccine; however, further investigation has not confirmed this finding. Similarly, OMV vaccines constructed from local outbreak strains in Cuba and New Zealand have had reported efficacy rates of >70%.
Ciprofloxacin or ofloxacin is preferred in some countries; these agents are highly effective and can be administered by mouth but are not recommended in pregnancy.
A further decline in the overall incidence of gonorrhea in the United States over the past quarter-century may reflect increased condom use resulting from public health efforts to curtail HIV transmission. This event initiates gonococcal phagocytosis and transport through these cells to intercellular spaces near the basement membrane or directly into the subepithelial tissue. Porin can translocate to the cytoplasmic membrane of host cells—a process that could initiate gonococcal endocytosis and invasion. For example, gonococci that are sialylated at their LOS sites bind complement factor H and inhibit the alternative pathway of complement.
Alterations in DNA gyrase and topoisomerase IV have been implicated as mechanisms of fluoroquinolone resistance.
Infection in the urethra and in Skene’s and Bartholin’s glands often accompanies gonococcal vaginitis.
Gonococcal isolates with a mutation in mtrR (multiple transferable resistance repressor) or in the promoter region of the gene that encodes for this transcriptional repressor develop increased resistance to antimicrobial hydrophobic agents such as bile acids and fatty acids in feces and thus are found with increased frequency in MSM. Pharyngeal colonization with Neisseria meningitidis needs to be differentiated from that with other Neisseria species. Lytic enzymes from the infiltrating PMNs occasionally cause corneal ulceration and rarely cause perforation. Other conditions and microorganisms, including Mycoplasma hominis, Ureaplasma urealyticum, C. Pharyngeal colonization has been demonstrated in 35% of infants with gonococcal ophthalmia, and coughing is the most prominent symptom in these cases.
A proposed mechanism is the significantly greater number of CD4+ T lymphocytes and dendritic cells that can be infected by HIV in endocervical secretions from women with nonulcerative STIs than in those from women with ulcerative STIs. If plates cannot be incubated immediately, they can be held safely for several hours at room temperature in candle extinction jars prior to incubation. Nucleic acid amplification tests (NAATs), including the Roche Cobas® Amplicor, Gen-Probe APTIMA COMBO 2®, and BD ProbeTec™ ET, also detect C. Spectinomycin has been used as an alternative agent for the treatment of uncomplicated gonococcal infections in penicillin-allergic persons outside the United States but is not currently available in this country.
These vaccines generate an antibody response to PRP in infants and effectively prevent invasive infections in infants and children.
Quadrivalent conjugate vaccines with tetanus or CRM197 as carrier protein are now available in many countries.
Resistance to fluoroquinolones has been reported in some meningococci in North America, Europe, and Asia.
At present, the attack rate in the United States is highest among 15- to 19-year-old women and 20- to 24-year-old men; 60% of all reported cases occur in the preceding two groups together.
LOS sialylation may also decrease nonopsonic Opa-mediated association with neutrophils and inhibit the oxidative burst in PMNs.
Rmp shows little, if any, interstrain antigenic variation; therefore, Rmp antibodies potentially may block antibody-mediated killing of all gonococci. The clinical manifestations of gonococcal urethritis are usually more severe and overt than those of nongonococcal urethritis, including urethritis caused by Chlamydia trachomatis (Chap. This situation may have been responsible for higher rates of failure of treatment for rectal gonorrhea with older regimens consisting of penicillin or tetracyclines. Septic arthritis (see below) is the most common manifestation of systemic infection or DGI in the newborn. If processing is to occur within 6 h, transport of specimens may be facilitated by the use of nonnutritive swab transport systems such as Stuart or Amies medium.
Of note, the limited effectiveness of spectinomycin for the treatment of pharyngeal infection reduces its utility in populations among whom such infection is common, such as MSM. If the patient’s last sexual encounter was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated.
More resistant to host clearance mechanisms and to antibiotics than are planktonic bacteria, biofilms are associated with chronic and recurrent otitis media.
Of survivors, 6% have permanent sensorineural hearing loss, and about one-fourth have a significant handicap of some type. From the standpoint of ethnicity, rates are highest among African Americans and lowest among persons of Asian or Pacific Island descent. The binding of the unsialylated terminal lactosamine residue of LOS to an asialoglycoprotein receptor on male epithelial cells facilitates adherence and subsequent gonococcal invasion of these cells. The mechanism of blocking has not been fully characterized, but Rmp antibodies may noncompetitively inhibit binding of porin and LOS antibodies because of the proximity of these structures in the gonococcal outer membrane. 213); however, exceptions are common, and it is often impossible to differentiate the causes of urethritis on clinical grounds alone. Other manifestations of noninfectious dermatitis, such as nodular lesions, urticaria, and erythema multiforme, have been described. Partner-delivered medications or prescriptions for medications to treat gonorrhea and chlamydial infection diminish the likelihood of reinfection (or relapse) in the infected patient.
If more subtle handicaps are sought, up to half of survivors are found to have some neurologic sequelae, such as partial hearing loss and delayed language development. In male volunteers who have no history of gonorrhea, the net effect of these events may influence the outcome of experimental challenge with N.
For example, the terminal monosaccharide expressed by LOS determines the C-type lectin receptor on dendritic cells that is targeted by the bacteria.
The Gen-Probe and BD tests offer the advantage that urine samples can be tested with a sensitivity similar to or greater than that obtained when urethral or cervical swab samples are assessed by other non-NAATs or culture, respectively.
Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms.
In turn, the specific C-type lectin receptor engaged influences whether a TH1- or TH2-type response is elicited; the latter response may be less favorable for clearance of gonococcal infection. Because Rmp bears extensive homology to enterobacterial OmpA and meningococcal class 4 proteins, it is possible that these blocking antibodies result from prior exposure to cross-reacting proteins from these species and also play a role in first-time infection with N. Several amplification tests are now available on semiautomated or fully automated platforms. Greater emphasis must be placed on prevention by public health education, individual patient counseling, and behavior modification.
Although a number of other organisms may be responsible, many cases do not have a specific etiologic agent identified. Analysis of various genotypic and phenotypic markers, including16S ribosomal sequences, superoxide dismutase, outer-membrane protein P6, protein D, and fuculose kinase, can be used to distinguish these two species. No effective vaccine for gonorrhea is yet available, but efforts to test several candidates are under way.



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17.10.2013, author: admin
Category: Ways To Cure Bv


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