NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277

8810

ORIGINAL RESEARCH

GONORRHOEA IN MEN: DIAGNOSTIC ASPECTS AND

CHANGING ANTIBIOTIC SUSCEPTIBILITY PATTERN
Sandeep Nanda1, Sonia Barve1, Chandralekha Bhanujan2, Sachin P
Lohra2, Rupal Patel3, Govind L Ninama4, Kalpesh Mistry4
Author’s Affiliation: 1Medical college, Baroda; 2BJ Medical College, Ahmedabad; 3PS Medical College, Karamsad;
4GMERS, Gotri, Baroda
Correspondence: Dr. Sandeepkumar Nanda, Email: [email protected]

ABSTRACT

Background: Gonorrhea since the ancient times is causing significant morbidity. Though a number of methods
are available for diagnosis in men, culture still remains the gold standard. Gonococci are delicate and fastidious
bacteria but its remarkable ability to develop resistance to a variety of antibiotics makes it a major threat to
public health.
Objectives: To detect the incidence in symptomatic men and in vitro antimicrobial susceptibility pattern of the
gonococcal isolates.
Materials & Methods: - 100 urethral swabs from men with urethritis were screened for presence of gonococci
by gram stain and culture on Chocolate Agar and Modified Thayer-Martin medium. The isolated gonococci
were screened for Penicillinase production and susceptibility to antibiotics was subsequently carried out by
standard disc diffusion method.
Results: - Gonorrhoea was detected in 56 of the urethral swabs giving a incidence of 56%. The difference of
detection in gram stain and culture was insignificant (P>0.05). Of all the isolated gonococci considerable
resistance was seen to ciprofloxacin(46.4%), tetracycline(23.2%) and Penicillin(17%) with Incidence of PPNG
being 12.5%. All strains were uniformly sensitive to Spectinomycin and Cephalosporins.
Conclusions: - Neisseria gonorrhoeae is main etiological agent in urethritis in sexually active men and culture
though time consuming, costly and demands expertise is still better method for diagnosis as gives high isolation
rate and observe changing patterns in antibiotic susceptibility to commonly used antimicrobials.
and enriched and or selective medium3,4,5. For these
reasons diagnosis by
Keywords: Gonorrhoea, Men, Antibiotic
susceptibility

INTRODUCTION
Gonorrhea is one of the oldest known bacterial
diseases that was recognized as sexually transmitted
infection by 13th century but still causes significant
morbidity among sexually active individuals1. Global
estimates of disease are difficult to obtain but WHO
suggests that worldwide, 62 million new cases occur
annually. The greatest burden of disease falls upon
less developed countries so the highest incidence and
prevalence is found in Africa and South-East asia. In
India, the prevalence rate of gonorrhea is 3-19% 2.
Gonorrhoea caused by Neisseria gonorrhoeae, is
diagnosed presumptively by the presence of
intracellular and extracellular Gram negative cocci on
a Gram stain. Culture for the causative organism is
considered necessary, however, as it dies rapidly if
exposed to desiccating or oxidising conditions, so
isolation of gonococci requires good specimen
collection and bedside inoculation or suitable
transport, a moist carbon dioxide enriched atmosphere
 such as ELISA, immunofluorescence, DNA probes,
genetic transformation, polymerase chain reaction
(PCR). Though rapid, sensitive and specific, PCR has
several limitations; it needs costly equipment and
reagents, experienced technician, and the organism
culture was regarded as difficult and uncertain, but cannot be isolated in this method for further
many decades ago the problems were overcome, and investigation.5,6 On the other hand, culture, though
culture became the method of first choice for more time consuming, needs to maintain viable
diagnosis, and remains the "gold standard" against organism till culture is done and having less
which other methods are measured. However, culture sensitivity in some samples, is the method of choice
is by no means the only method available for for identification of gonococci, particularly in
diagnosis of gonorrhoea.3,4,5. developing countries because is cost effective, high
Alternative methods have been evaluated exclusively specificity and very important for testing
for the detection of gonococci in clinical specimen
Volume 3│Issue 2│Apr – June 2013 Page 177
NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810

the antibiotic sensitivity pattern that is another key 1. A sterile, calcium alginate tipped swab was
factor in successful treatment and control of disease 3,5. used for collection of discharge or sterile
Because of continuing drift towards decreased bacteriological loop was passed 3-4 cm into the urethra.
antibiotic sensitivity of Neisseria gonorrhoeae, One swab was used for smear preparation for Gram-
effective treatment of gonorrhea is hampered. staining and microscopical examination. Gram-stained
Emergence of gonococci with plasmid mediated and smears of urethral exudate were examined under x
chromosomally mediated resistance to penicillin and 1000 magnification oil immersion for the presence of
tetracycline resulted in use of quinolones for the polymorphonuclear cells and Gram-negative
treatment of gonorrhea. But Quinolone Resistant N. diplococci. The results of the smears were considered
gonorrheae (QRNG) resulted in the use of expanded positive if typical Gram-negative diplococci were seen,
spectrum Cephalosporins as the first line of treatment whether located intracellularly or extracellularly.
for uncomplicated gonorrhea. Because of the
2. And the second swab was streaked directly on
emergence of resistance to different antibiotics, the in
to an enriched medium, Chocolate Agar(CA) and
vitro estimation of antimicrobial sensitivity becomes
selective medium, Modified Thayer-Martin
necessary.7There has been little published work on
media(MTM) having Vancomycin, Colistin, Nystatin
gonococcal infection in men since before the 2nd
and Trimethoprim as selective agents and incubated
World War and much that is written reflects received for
information, passed down from previous authorities.8
48 hours in moist environment at 35-36°C in 5-10%
So this study was carried out in symptomatic male carbon dioxide. No cultures for viruses or chlamydiae
patients to know the incidence of gonococci in were carried out. A presumptive identification of
urethritis and evaluation of gram stain and culture isolates of Neisseria gonorrhoeae was based on
methods as well as role of enriched media and characteristic colonial morphology, positive oxidase
selective media in diagnosis of gonorrhoea and study test, and the presence of Gram-negative diplococci.
antibiotic susceptibility pattern of gonococci. Isolates were further identified as N. gonorrhoeae by
typical sugar utilization tests. All the isolated
gonococci were screened for production of
METHODS AND MATERIAL Penicillinase by acidometric method and antibiotic
sensitivity testing performed by disc diffusion method
Male patients with complaint of urethral discharge
against Penicillin, Tetracycline, Ciprofloxacin,
were examined after informed consent. Those
Spectinomycin, Cefuroxime and Ceftriaxone.
suspected of having gonorrhoea, discharge was
collected under sterile conditions and smears were
prepared for Gram staining and culture performed bed RESULTS
side on enriched media and selective media. For this
purpose two samples were taken one for culture and In the present study, gonococci were the etiological
second for smear preparation. agent in 56(56%) of the 100 symptomatic men that
presented with urethritis (Table 1).

Table 1: Incidence of gonorrhea and Evaluation of Chocolate agar (CA) and Modified Thayer Martin
(MTM) medium in isolation of gonococci
Authors Total Gonococcal isolates (%) No. of isolations on specific media
MTM + CA MTM only CA only
Present study 100 56(56%) 53 03 00
Jacob et al9 375 169(45%) 158 10 01
Bonin et al10 6236 868(13.9%) 839 16 13

Majority of patients (78.6%) with gonorrhea were tetracycline and ciprofloxacin respectively. Resistance
between 15 to 29 yrs of age and 94.6% gave history of to penicillin was observed in 10 (17.8%) of the
unprotected sexual exposure to CSWs while 5.4% isolates of which Penicillinase producing Neisseria
were homosexuals. Diagnosis of gonorrhea was gonorrhoeae (PPNG) were seen in 7(12.5%) of the
established by Gram stain in 53% and by culture in isolates (Table 3).
56% of the patients but the difference of positivity is
not statistically significant (P>0.05) (Table 2).
Gonococci were isolated on both MTM and CA in 53 Table 2: Evaluation of smear in comparison with
cases, on MTM only in 3 and no isolation on CA only. culture in diagnosis of gonorrhea
So all the isolates grew on MTM and only 3 were not Authors Positive by Positive by
isolated on CA. Though the rate of isolation is higher smear (%) culture
on MTM in comparison to CA, the difference is not Present study (n =100) 53(94.6) 56
statistically significant (P>0.05) (Table 1).All the Manis et al11 (n=295) 98(95.1) 103
isolates were susceptible to Spectinomycin,
Cefuroxime and Ceftriaxone. While 23.2% and 46.6%
were resistant to
Volume 3│Issue 2│Apr – June 2013 Page 178
NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277
8810

Table 3: Antibiotic resistance pattern of gonococci

study Penicillin (%) Tetracycline Ciprofloxacin Spectinomycin Cefuroxime Ceftriaxone

PPNG Non PPNG (%) (%) (%) (%) (%)

Present study (n=56) 7 (12.5) 3 (5.3) 13(23.2) 26(46.4) 00 00 00
Lesmana et al (n=122) 77 (63.1) 6 (4.9) 119(97.5) --- 00 00 00
Berron et al (n=400) 150 (37.5) 16 (4) 129(32.2) 26(6.5) 00 ---- 00

DISCUSSION 20-29years of age and gave history of unprotected,

multiple, heterosexual exposure to CSWs (94%). As
Among the symptomatic males gonococcal urethritis
for establishing diagnosis, though Gram stain is rapid,
is the predominant (56%). Similar results are reported
cost effective, highly sensitive and specific in
by Jacob et al9 (P>0.05) but the incidence is
symptomatic men we still recommend use of culture
significantly different with that of Bonin et al10
along with Gram stain. Culture though time
(P<0.01) (Table 1). This difference is because in
consuming, costly, requires special set up and
present study only cases of symptomatic urethritis
technical expertise and viable organism for isolation
have been included while Bonin et al included all
will help in diagnosis in missed out cases and perform
male patients undergoing urethral culture whether for
Antibiotic sensitivity testing considering changing
diagnosis, screening or test of cure. On comparison
patterns in the sensitivity profile of organism4. As for
with study of Manis et al11, the rate of positivity of
choice of culture media whether enriched (CA) or
smear in diagnosis of gonorrhea is not statistically
selective (MTM), we recommend both, because MTM
significant (P>0.05) (Table 2). Similar results were
have higher isolation rate but some strains of
reported by Sherrard et al 8 94% positivity of smear in
gonococci are sensitive to Vancomycin and are
symptomatic men. These results further confirm that
inhibited on MTM are isolated only on CA. Due to
Microscopy of a gram-stained urethral sample is a
high prevalence PPNG and resistance in gonococci to
highly sensitive examination in diagnosis of
Penicillin, Ciprofloxacin and Tetracycline it is
gonorrhoea when compared to culture in symptomatic
mandatory to perform antibiotic sensitivity testing and
men, although its sensitivity is much reduced in
observe the changing pattern in antibiotic
asymptomatic men, even when most of these are
susceptibility pattern. However, because no resistance
presenting as known contacts of gonorrhoea, and the
is observed to Cephalosporins these are the drugs of
index of suspicion of the microscopist is high 8. On
choice for management of Gonorrhoea.
comparing result of present study for isolation on CA
and MTM with that of Jacob et al 9 and Bonin et al10, it
was observed that the difference was not statistically REFERENCES
significant (P>0.05, CI 95%). However, in both the
studies some isolates (1 in Jacob et al and 13 in Bonin 1. Tiwari VD, Talwar S, Grewal RS. Urethritis, pelvic
inflammatory disease and Reiter,s disease. In Valia RG, Valia AR
et al) were isolated only on CA that may be because
(eds) IAVDL Textbook And Atlas of Dermatology. 2nd edition; Vol
some strains of gonococci are susceptible to II; Bhalanipublications:1423–1451.
Vancomycin that inhibits growth on MTM which
2. Vinod k. Sharma, Sujay khandpur. Changing pattern of
justifies use of Lincomycin in selective media instead sexually transmitted infection in India. The National Medical journal
of Vancomycin. and use of both enriched media and of India 2004;17(6):310-319
selective media in isolation of gonococci 3,5,12. 3. Koneman EW, Allen SD, Janda WM, Schrenckenberger PC,
Antibiotic susceptibility pattern of gonococci in Winn WC. Neisseria species and Moraxella catarrhalis. In Koneman
different geographical areas shows a lot of variation EW, Allen SD, Janda WM, Schrenckenberger PC, Winn WC (eds)
and very high resistance to commonly used antibiotics Color Atlas and Textbook of Dignostic Microbiology. Fifth edn.
Lippincott Williams and Wilkins:491– 538.
suggesting continuous monitoring of the susceptibility
pattern to avoid over exposure to resistant 4. Ison CA. Methods of diagnosing gonorrhea. Genitourinary
antimicrobials.13,14,15 Lesmana et al13, Berron et al14 medicine 1990;66:453 –59.
and Bhalla et al7,15 in different studies in different 5. A E Jephcott. Microbiological diagnosis of gonorrhoea.
geographical areas at different times also observed 0% Genitourin Med 1997;73: 245-52.
resistance to Spectinomycin and Cephalosporins. 6. Alam MA, Milah MRA, Rahman M, Sattar H, Saleh AA.
However, in all the forementioned studies the Comparison of PCR method with the culture method for
resistance to Tetracycycline was 64%7, 98%13 and identification of gonococci from endocervical swabs. Indian Journal
of Medical Microbiology 2002;20(1):37–39.
32%14, Ciprofloxacin was 6.5%14 and 75%15 and to
Penicillin was 12%7, 68%13 and 41%14. This shows a 7. Bhalla P, Sethi K, Reddy BSN, Mathur MD. Antimicrobial
susceptibility and plasmid profile of Neisseria gonorrheae in India
lot of variation in resistance pattern in different (New Delhi). Sexually Transmitted Infections 1998;74:210 –212.
geographical areas at same time and from time to time
8. J Sherrard, D Barlow. Gonorrhoea in men: clinical and
in the same region.7,13,14,15 diagnostic aspects. Genitourin Med 1996;72:422-426.

CONCLUSION
From the present study, we conclude that Neisseria 9. Jacobs NF Jr., Kraus SJ. Comparison of hemoglobin free culture
gonorrhoeae is the predominant cause (56%) of media and Theyer – martin medium for primary isolation of
urethritis in men. Majority of the patients were in age
group of
Volume 3│Issue 2│Apr – June 2013 Page 179
NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810
Neisseria gonorrheae. Journal of Clinical Microbiology 13. Lesmana M, Lebron CI, Taslim D, Tjaniadi P, Subekti D, Wasfi
1975;1(5):401 –404. MO et al. In vitro antibiotic susceptibility of Neisseria
gonorrheae in Jakarta, indonesia. Antimicrobial Agents And
10. Bonin P, Tanino TT, handsfeild HH. Isolation of Neisseria
Chemotherapy 2001;45(1):359–362.
gonorrheae on selective and non selective media in sexually
transmitted disease clinic. Journal of Clinical Microbiology 14. Berron S, Vazquez JA, Gimenez MJ, Feunte de la L, Aguilar L.
1984;19(2):218-220. in vitro susceptibility of 400 spanish isolates of Neisseria
gonorrhea to gemifloxacin and 1 other antimicrobial agents.
11. Manis RD, Harris B, Grisler PJ. Evaluation of Gonozyme, an Antimicrobial Agents And Chemotherapy 2000;44(9):254–
2544.
enzyme immuno assay for rapid diagnosis of gonorrhea. Journal
of Clinical Microbiology 1984;20:742 –746. 15. Bhalla P, Vidhani S, Reddy BS, Chowdhry S, Mathur MD.
Rising quinolone resistance in Neisseria gonorrheae isolates
12. Young H. Cultural diagnosis of gonorrhoea with modified New
from New Delhi. Ind J Med Res 2002;15:113– 117.
York City (MNYC) medium. BrJ' Vener Dis 1978;54:36-40.
Volume 3│Issue 2│Apr – June 2013 Page 180