Original StudyCulture of Non-Genital Sites Increases the Detection of Gonorrhea in Women
Introduction
Genital gonorrhea is a national public health concern because of its high prevalence and ability to cause serious sequelae among infected women. The national prevalence of 118 genital cases per 100,000 women in 2007 is much higher than the goal of 19 cases per 100,000 women set by Healthy People 2010.1, 2 Ominously, surveillance shows that between 2004 and 2007, the prevalence in Cincinnati has increased from 193 to 267 cases per 100,000 women. While over 95% of women with cervical gonorrhea are asymptomatic,3 women with gonorrhea are at risk for serious consequences such as pelvic inflammatory disease4, 5 and disseminated gonococcal infections.6, 7 The high proportion of asymptomatic infections makes screening of “at risk” women necessary because untreated cases present risks to the patient and can lead to transmission to others. Thus, current guidelines recommend screening all sexually active women under age 26 for genital gonorrhea.8
In addition to the urogenital tract (cervix and urethra), gonorrhea can also infect the rectum and pharynx. In most of these cases, concurrent cervical infection is present. For example, older studies have shown that while up to 60% of adult women with cervical gonorrhea also have a positive rectal culture, isolated rectal infections are reported in 2–10% of cases.9, 10 Untreated rectal infections can lead to symptomatic proctitis and are a significant source of disease transmission for men who have sex with men. However, the consequences for women are not well defined. The overall prevalence of pharyngeal gonorrhea in women in older studies ranges from 2–5%, and up to 20% of women with cervical gonorrhea were co-infected at the pharynx.11, 12, 13 However, isolated pharyngeal infection occurred in only 2–5% of infected women. The clinical importance of untreated pharyngeal infections in women is still unclear. Some studies have shown spontaneous resolution of pharyngeal infection.14, 15 However, other studies have shown that pharyngeal gonorrhea in women can be transmitted to a male partner during fellatio.12, 13 It is estimated that up to 2% of gonococcal urethritis cases result from fellatio.11 In a 1989 study of adolescent women, routine pharyngeal culturing showed no isolated pharyngeal infections in a low risk (3.5% prevalence) population, and only 1% of infected women had isolated pharyngeal infections in a high risk (33% prevalence) population.16 We could find no recent studies examining the benefit of screening for asymptomatic rectal and pharyngeal gonorrhea in adolescent women.
In Cincinnati's sexually transmitted disease (STD) clinic, providers obtain a comprehensive sexual history and routinely screen women for asymptomatic rectal and pharyngeal gonorrhea if a history of oral or anal sex is given. In other settings, providers vary in their ability to obtain a complete sexual history, and culture of non-genital sites is a matter of provider choice. In either setting, some patients may under-report oral or anal sexual practices. Therefore, it is possible that the pharynx or rectum could be a reservoir for gonorrhea that helps to maintain high rates of infection in young women in Cincinnati.
There are three main objectives for this study: First, we wish to update the estimates that are several decades old of oral and rectal gonorrhea prevalence in women. Second, in our city, with its known high prevalence of genital gonorrhea, we wish to compare the prevalence of cervical, pharyngeal, and rectal gonorrhea in three groups: adolescent women 14–21 years old and adult women over 21years old attending an STD clinic, and adolescent women 14–21 years old seen at a children's hospital. Finally, we wish to determine if culturing the rectum and pharynx increases detection of gonorrhea in any of these groups above culture of the cervix alone. These findings may inform clinical decisions to offer screening for non-genital gonorrhea infections and may allow a cost-benefit analysis of expanded testing in the future. Such information may direct efforts to control the epidemic of gonorrhea in high-prevalence areas such as Cincinnati.
Section snippets
Materials and Methods
This study was a retrospective review of de-identified data from two sources. We reviewed two years of data (2006–2007) from an electronic clinical database at the local health department's STD clinic. From this database, we exported de-identified data that was limited to age, source of gonorrhea culture, and culture result. During this time frame, all gonorrhea testing was performed using culture, and nucleic acid amplification was not available. We stratified this sample into those aged 14–21
Results
From the STD clinic there were 1949 visits that included a cervical culture. Gender and race were not indicated in the STD database, so cervical culture was used as a proxy for female gender. Twenty-seven percent of women at the STD clinic (n=525) were age 14–21, matching the children's hospital sample, and the remainder (n=1424) were over age 21. From the children's hospital there were 16,039 patient visits made by adolescent and young adult females aged 14–21 years that included at least one
Discussion
We were surprised to discover that the prevalence of cervical and pharyngeal gonorrhea among adolescents seen in a children's hospital setting matched the rates of infection among adolescent women at an STD clinic. These findings are in contrast to those reported by Brown et al in a 1989 study.16 Additionally, we showed that among women seen at an STD clinic, the prevalence of pharyngeal gonorrhea is higher in adolescent women (age 14–21) than in adult women (over age 21), even with a practice
Conclusions
Our data reflect current practices, where culturing of non-genital sites is routine in an STD clinic and rare in an adolescent population of women. In the STD clinic, culturing of the cervix, pharynx, and rectum increases the number of infected women detected over single cervical culture, and should be advocated. Because adolescent women may not report sexual behaviors as accurately as adult women, “routine” culturing of the pharynx and rectum may improve the detection of infected individuals.
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Cited by (20)
Routine universal testing versus selective or incidental testing for oropharyngeal Neisseria gonorrhoeae in women in the Netherlands: a retrospective cohort study
2021, The Lancet Infectious DiseasesCitation Excerpt :Future research should assess the cost-effectiveness of a routine universal testing approach and the clinical and public health impact of routine universal testing on N gonorrhoeae control and the control of antimicrobial resistance. A small number of studies done in women have reported that the prevalence of oropharyngeal N gonorrhoeae ranges from 0% to 9%.8–17 Most studies in women have focused on sex workers, since they are an internationally recognised risk group for sexually transmitted infections (STIs).8–12
Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused
2016, Journal of Pediatric and Adolescent GynecologyCitation Excerpt :Although the CDC still recommends culture for nongenital sites, many practitioners find it difficult to access cultures. NAATs have been evaluated in adult studies for pharyngeal24,25 and anorectal26,27 infections. NAATs (especially strand displacement amplification [SDA] and transcription mediated amplification [TMA]) have been found to have superior sensitivity to detecting infection at these sites compared with culture and specificity rates that are well within the range of acceptable for clinical practice.
Control of Neisseria gonorrhoeae in the Era of evolving antimicrobial resistance
2013, Infectious Disease Clinics of North AmericaCitation Excerpt :Studies conducted in the 1970s and 1980s found that among women with genital tract infections with N gonorrhoeae, approximately 10% to 25% had concurrent pharyngeal gonorrhea,33–36,40–42 and nearly 40% had concurrent rectal infection.42 However, isolated extragenital infections (without concurrent cervical infection) in women were not common in those studies, and the US CDC does not recommend extragenital screening for women.42–45 However, recent studies showing higher rates of extragenital coinfection have stimulated interest in revisiting extragenital screening recommendations for women.43,46
Diagnosis and management of gonococcal infections
2012, American Family PhysicianCitation Excerpt :Sepsis, neonatal conjunctivitis (ophthalmia neonatorum), meningitis, and arthritis are the most severe complications.1 Other manifestations include pharyngitis, rhinitis, vaginitis, urethritis, and, rarely, pneumonia.1,5 Infants may develop localized scalp infections or abscesses from open wounds, such as those caused by fetal scalp electrodes.