Patterns of Presentation in Gonococcal Urethritis and Assessment of Antibiotic Sensitivity in Gonorrhea

Objective: To see various features of Gononcoccal Urethritis and assess the results of Gram stain and culture tests in cases of Gonorrhea and to see the antibiotic resistance pattern in them, in our local population (PNS Shifa hospital Karachi, Pakistan). Design: Prospective case series. Place and duration of study: Skin department of PNS Shifa Hospital Karachi, Pakistan. June 2004 to December 2007. Materials and methods: The study was carried out in the outpatient dermatology department of PNS Shifa hospital Karachi during the period from June 2004 to Dec 2007. It was a prospective study. One hundred clinically suspected patients of Gonococcal urethritis were included in the study. Detailed history including history of sexual contact was taken. General and systemic physical examination was carried out in all the patients. Dermatological examination including examination of external genitalia was also done. In all these patients following investigations were carried out. Urine complete examination ,complete blood counts, pus sample was collected from external urethral meatus by two sterile inoculating loops on to a clean glass slide for Gram staining which was seen under the microscope for the presence of gram-negative diplococci. The other loop was inoculated onto chocolate agar plate and was incubated in an atmosphere of 5% CO2 at 37oC for 24-48 h. The growths obtained were identified with colony morphology, Gram staining, oxidase reaction and rapid sugar fermentation. The Gonococci isolated were tested for antibiotic sensitivity using modified Kerby buer technique. The antibiotics included Penicillin G, Tetracycline, Cefotaxime, Cefuroxime, Ceftriaxone and Ciprofloxacin. HIV test was done in all patients. The results of two types of tests and their merits and demerits were assessed and compared.. Results: A total of 100 patients having urethral discharge and dysuria were studied. All the patients were males. The ages varied from 20 to 40 years, the average being 29.2 years+5.8 years. History of illicit sexual exposure was elicited in 43 (43%) patients. The duration of period of symptoms ranged between 4 and 30 days with a mean of 12.8 days and a median of 12 days. The patients with gonorrhea presented with purulent discharge in 66 (66%) cases, and dysuria in 49 (49%) cases. No case had anal or oral symptoms. Examination showed a reddened external urethral meatus in 53(53%) cases. Eighty seven (87%) cases showed intracellular diplococci on direct microscopy of Gram stained smear. Sixty-two (62%) cases showed growth of gonococci on culture of urethral pus. No case was seen to be HIV positive. Tetracycline resistance was seen in 34(55%) strains. Penicillin resistance was seen in 25 (41%) strains of Neisseria Gonorrhea. Five strains (11.5%) showed resistance to Ciprofloxacin. No resistance was seen with Cephalosporins. Conclusion: Gram staining and culture for Neisseria Gonorrhea are both useful diagnostic tests for Gonococcal urethritis. Drug resistance of Neisseria Gonorrhea is high with various antibiotics except for Cephalosporins stressing the need for culture based therapy and enthusiastic prevention of Gonorrhea in our society.