WS 268-2007Diagnosis for gonorrhoea (English PDF)

3.1 Epidemiological history

There is a history of unsafe sexual behavior, or a history of sexual partner infection, or a history of multiple sexual partners. Mothers of neonates have a history of gonorrhea.

3.2 Clinical manifestations

3.2.1 Incubation period

1 d ~ 10 d, often 3 d ~ 5 d.

3.2.2 No complication gonorrhea

3.2.2.1 Male gonococcal urethritis The initial symptoms are urethral itching, thin or mucopurulent secretions, and most patients have symptoms after 24 hours.

Drama, urinary pain, burning sensation, increased secretions, thick viscous pus, may be accompanied by frequent urination, urgency. In severe cases, glans can appear.

The inside of the foreskin is red and swollen, with exudate or erosion, foreskin edema, and can be incarcerated with the foreskin. Physical examination revealed redness, swelling, and purulent secretions in the urethra.

3.2.2.2 Female symptoms are milder than men's, and some patients may have no obvious symptoms. Gonorrhea in adult women mainly causes cervicitis, which can be simultaneous or separate There are urethritis, symptoms often appear leucorrhea increased, yellow, and some with lower abdominal pain, dysuria, frequent urination and urgency. Cervical congestion during gynecological examination, Redness, easy to contact with bleeding, mucus purulent discharge in the cervix. The girl patient presented with diffuse vaginitis secondary to vulvitis, visible vaginal opening, the urethra and perineum are red and swollen. The lesions may have erosion, ulcers and pain. The vagina has purulent secretions and dysuria.

3.2.3 Comorbid gonorrhea

3.2.3.1 Some patients may have comorbidities when the treatment is not timely. Men are mainly epididymitis, orchitis and prostatitis. Epididymitis, orchitis the onset is acute. At the beginning, the scrotum or testicles have traction pain, progressively worsening, and spread to the groin, often with fever and general malaise. Check can See epididymis, testicular swelling, tenderness, and when the condition is severe, it can touch the enlarged spermatic cord and inguinal lymph nodes. Epididymis connective group Perforation, fibrosis, and vas deferens block, causing infertility. Prostatitis is characterized by fever, dysuria, frequent urination, urgency, and urinary incontinence.

Perineal pain, prostate anal examination has obvious tenderness and swelling. There are a large number of pus cells and lecithin bodies in prostate secretions. In addition, male Sex can also be complicated by other complications such as paraurethritis, periurethal abscess, cavernitis, balanitis or glans dermatitis, urethral stricture.

3.2.3.2 Female comorbidities are mainly pelvic inflammatory disease, including endometritis, salpingitis, fallopian tube ovarian abscess, peritonitis and so on. Occasionally for women of childbearing age, most patients have increased vaginal discharge and are purulent or bloody. Systemic symptoms such as chills, fever, headache, anorexia, nausea, Vomiting, double lower abdominal pain. Examination can be seen in the lower abdomen tenderness, and muscle tension, purulent secretions in the urethra, cervix, etc. Can develop into fallopian tubes Ovarian abscess or pelvic abscess, at this time, the tumor can be touched at the attachment and the posterior vaginal fornix. The tenderness is obvious, and there is a sense of fluctuation if the abscess is broken.

Crack, there are manifestations of peritonitis and even toxic shock, which can cause tubal adhesions, obstruction and even infertility or ectopic pregnancy. In addition to women can also be complicated by vestibular gland inflammation, manifested as vestibular glandular redness, pain, purulent discharge at the opening of the gland, 1/2 swelling under the labia majora Significant, may also be associated with systemic symptoms and inguinal lymphadenopathy.

3.2.4 Gonorrhea outside the genitourinary tract

3.2.4.1 Gonococcal ophthalmia

Neonatal gonococcal ophthalmia is often caused by infection in the birth canal of gonorrhea mothers, mostly bilateral, usually occurring within 3 days after birth.

shape. Adult gonococcal ophthalmia is mostly caused by self-inoculation infection or close contact with items contaminated by secretions, unilateral or bilateral. Clinical manifestation Conjunctival congestion and edema, a large amount of purulent secretions, the cornea can lose luster after treatment, and then ulceration, even perforation and whole eyes Ball inflammation can eventually lead to blindness.

3.2.4.2 Gonococcal pharyngitis

Mainly due to oral sex. Most patients have asymptomatic or mild symptoms, and a small number can present with pharyngeal pain, burning, and difficulty swallowing. Physical examination it can be seen that the pharyngeal mucosa is hyperemia, the tonsils are red and swollen, and purulent secretions are attached to the posterior pharyngeal wall.

3.2.4.3 Gonococcal proctitis

More common after anal sex. Most patients have asymptomatic infections, and a few have anal itching, pain or bulging sensation, exacerbation during defecation, and pus Sex secretions are discharged. Physical examination revealed swelling, congestion, erosion, and oozing of the rectal mucosa.

3.2.5 Disseminated gonococcal infection

Neisseria gonorrhoeae spreads through the bloodstream to the body, which is rare in clinical practice. It is characterized by fever, chills, skin lesions, joint pain and so on. Skin lesions start with red Small papules, erythema, and then blisters or pustules. Joint involvement occurs in the joints of the knee, elbow, wrist, etc., which is characterized by joint pain, local swelling, the effusion and joint activity in the joint cavity are limited, which is gonococcal arthritis. Fatal complications such as gonococcal meningitis, endocarditis, Pericarditis, myocarditis, perihepatitis and even sepsis.

3.3 Laboratory inspection

3.3.1 Smear Gram stain microscopy

Clinically suspected patients take secretions, smears, and Gram stain microscopy, showing typical Gram-negative diplococcus in polymorphonuclear leukocytes. Have Male gonococcal urethritis with obvious urinary tract symptoms is positive for microscopic examination of urethral secretion specimens. See Appendix A.

3.3.2 Neisseria gonorrhoeae culture

Taking urethral or cervical secretions, or other clinical specimens for gonococcal culture, can be isolated from clinical specimens, typical oxidase test Test positive colonies. Taking colonies for smear examination, Gram-negative diplococcus can be seen. The sugar fermentation test decomposes glucose and does not decompose other sugars.

3.3.3 Neisseria gonorrhoeae nucleic acid detection

Take urine, urethra or cervical secretion specimens for positive detection of gonococcal nucleic acid, see Appendix B.

5.1 Suspected cases

Cases of male gonococcal urethritis met 3.1 and 3.2; other cases met 3.1, 3.2, and 3.3.1.

5.2 Confirmed cases

Male cases of gonococcal urethritis meet 3.1 and 3.2, and meet any of 3.3; other cases meet 3.1 and 3.2, and meet 3.3.2 or 3.3.3.

6.1 Genital chlamydia trachomatis infection

The incubation period is long, with an average of 1 week to 3 weeks, and the symptoms are mild or asymptomatic. Mainly manifested as tingling or itching of the urethra, some accompanied by light and heavy Frequent urination, urgency, and dysuria. The urethral opening or cervical congestion, edema, may have a small amount of thin serous or serous purulent secretions. Chlamydia trachomatis Check positive.

6.2 Other

6.2.1 Non-specific urethritis

Bacterial urethritis unrelated to sexually transmitted diseases, such as urinary tract infection secondary to phimosis, or secondary to urethral catheterization and other urethral instruments Infection after injury caused by operation. Microscopic examination is often Gram-positive cocci.

6.2.2 Candida vaginitis

Vulva, vaginal itching, increased vaginal discharge, white curd-like or bean curd-like, can have odor, size and swelling of the labia, vaginal mucosa Congestive edema, with a milky white film adhesion, removal of the film visible mild erosion, white film microscopic examination showed a large number of ovate spores and pseudohyphae.

6.2.3 Trichomonas vaginitis

Itching of the vulva, a large amount of yellow-white or yellow-green secretions, foamy, stinking, vaginal mucosa and cervix are obviously congested and spotted Point-like hemorrhage, the cervix can be characterized by a strawberry-like appearance, and the secretion can be seen by microscopic examination.

6.2.4 Bacterial vaginosis

Increased leucorrhea, grayish white or gray-green, uniform as a batter-like adhesion to the vaginal wall, fishy stench, pH increase, amine test Positive, smear showed a decrease in lactobacilli, increased Gram-negative bacteria, and a large number of elliptical short rod-shaped Gatnerella, which can be found in clue cells.

Appendix A

(normative appendix) Laboratory diagnostic method for gonococcal infection A.1 Collection of specimens A.1.1 Drawing swabs Calcium alginate swabs, ordinary cotton swabs and polyester swabs can be used, but the nucleic acid test should use the kit to support the swab.

A.1.2 Drawing parts

The susceptible cells of Neisseria gonorrhoeae are columnar epithelial cells. Should be based on the patient's age, gender, sexual contact, clinical performance and diagnostic test the method determines the appropriate location for specimen collection. Multiple sites in the same patient can increase the positive rate of detection. For male heterosexual patients, generally Only urethral specimens were collected, and those with oral history were added to the pharyngeal specimens; for men who have sex with men, urethral, rectal, and pharyngeal specimens should be collected;

The cervical specimens are routinely collected, and if necessary, materials are taken from the urethra, rectum, pharynx, vestibular gland, and paraurethral gland; vaginal secretions are collected from young girls;

For patients with disseminated gonococcal infection, blood, joint fluid or skin lesion specimens may be collected in addition to urogenital specimens. For neonatal ophthalmitis patients Collect eye conjunctival secretions and collect cervical, urethral or rectal specimens from their mothers.

A.1.3 Collection methods for different types of specimens A.1.3.1 Urethral swabs for male patients, first wash the urethral orifice with saline, insert the male swab into the urethra 2 cm to 3 cm, and turn it slightly.

Leave it for 5 s to 10 s. For female patients, the fingers can be used to gently massage the urethra along the female urethra after the pubic symphysis.

A similar method is used. The patient should have no urination for at least 1 h before collecting the urethral swab.

A.1.3.2 Cervical swab Wet the diffuser with warm water or normal saline before taking the material. Avoid using preservatives and lubricants because of the growth of Neisseria gonorrhoeae.

It has an inhibitory effect. If there is more secretion outside the cervix, use a sterile cotton swab to remove excess secretions. Insert a female swab into the palace 1 cm ~ 2 cm inside the neck tube, rotate slightly, retain it after 5 s ~ 10 s.

A.1.3.3 rectal swab

Insert the swab into the anal canal 2 cm ~ 3 cm, contact the side wall of the rectum for 10 s, avoid contact with the fecal mass, take from the crypt close to the anal ring Excretion. If the swab touches the dung, replace the swab and re-take the material. Rectal mucus purulent can be collected under direct vision of the proctoscope when conditions permit Secretion.

A.1.3.4 Vaginal swab Pre-adolescent girls can collect vaginal specimens. The sputum swabs were placed in the vagina for 10 s to 15 s, and vaginal secretions were collected. in case If the hymen is intact, take it from the vaginal opening.

A.1.3.5 throat swab

The swab is taken into contact with the posterior pharyngeal wall and the tonsil crypt to collect secretions.

A.1.3.6 Conjunctival swab Open the lower eyelid and collect the secretion from the lower conjunctiva surface with a swab.

A.1.3.7 Urine

The patient should have no urination for at least 1 h before collecting the urine specimen. Collect the anterior urine 10 mL to 20 with a sterile, preservative-free plastic container.

mL. Urine detected within 24 h should be stored in a refrigerator at 4 ° C. When tested for more than 24 h, it should be stored in a refrigerator at -20 ° C or -70 ° C.

A.1.4 Delivery of specimens Neisseria gonorrhoeae is weak, sensitive to heat and not resistant to dryness. If the specimen is not immediately inoculated into the separation medium, it should be placed in the transport.

In the medium. Amies medium and Stuart medium are two commonly used non-nutritive delivery media. Specimen placed in transport medium it should be sent to the laboratory within 12 h and inoculated in a selective isolation medium with a positive rate of over 90%. Separation positive over 24 h the rate drops.

A.2 Laboratory diagnostic methods A.2.1 Gram staining microscopy A.2.1.1 Instruments and materials Microscope and Gram dye solution.

A.2.1.2 Gram staining method A.2.1.2.1 Smear fixation. After taking the material, gently swab the swab on the slide to make a thin and even smear. After drying, it will be coated.

The sheet (the coating film faces up) is quickly passed through the flame 2 times to 3 times and fixed by heating. Excessive heating should be avoided to distort cell morphology.

A.2.1.2.2 Gram staining steps are as follows.

1) Spread the crystal violet solution on the coated surface of the smear, dye for 30 s to 60 s, and rinse gently with running water.

2) Spread the iodine solution on the surface of the coating and dye it for 30 s to 60 s. Rinse gently with running water.

3) Decolorize with ethanol or acetone until the coating film has no blue to remove. It usually takes 10 s to 20 s (the length of time depends on the thickness of the smear) Thin, should avoid excessive discoloration), rinse gently with running water.

4) Re-dye with alkaline red or sand yellow dye solution for 60 s, rinse with running water and gently blot dry with absorbent paper.

A.2.1.2.3 Observation of results. The smear was examined under an optical microscope (100x objective or oil mirror). Pay attention to the cell type when checking (eg Epithelial cells, polymorphonuclear leukocytes), staining characteristics of pathogens (gram positive or negative), shape (spherical or rod-like) and position (intracellular or Extracellular) and so on. Neisseria gonorrhoeae are Gram-negative bacteria, often arranged in pairs, the cells are kidney-shaped, the long axis of the two bacteria is parallel, and the contact surface is flat or slightly concave.

In polymorphonuclear leukocytes.

A.2.1.2.4 Report of results. Positive morphologically positive pairs of Gram-negative diplococcus were found in polymorphonuclear leukocytes; polymorphonuclear leukocytes it is suspected that the typical Gram-negative diplococcus is suspicious; with or without polymorphonuclear leukocytes but not Gram-negative diplococcus (may report only Polymorphonuclear leukocyte count).

A.2.1.2.5 Clinical significance. The sensitivity and specificity of Gram staining depends on the type of specimen. For urethra from male gonococcal urethritis the secretion specimens have a sensitivity and specificity of up to 95% to 99%, and have diagnostic value. But detecting cervical specimens, asymptomatic male urethra when the swab and the specimen are taken from the rectal specimen, the sensitivity is only 40% to 70%, so it should be identified by separate culture method. Gram staining is not recommended Direct microscopy to diagnose rectal and pharyngeal gonococcal infections, and can not be used for healing after treatment. If you see a morphology outside the polymorphonuclear leukocytes Typical Gram-negative diplococcus needs to be cultured for confirmation.

A.2.2 Isolation and culture of Neisseria gonorrhoeae A.2.2.1 Medium Separation of Neisseria gonorrhoeae generally uses a nutrient-rich selective medium. Commonly used selective media with improved Thayer-Martin (TM) Medium, antibiotic-containing blood agar or chocolate agar medium. Commercially available media or laboratory self-contained, the medium should be dense it is sealed in a plastic bag and stored in a refrigerator at 4 ° C. The storage time should not exceed 3 weeks. If the time is too long, the separation rate will decrease. The description is as follows.

a) Thayer-Martin(TM) medium

1) Ingredients. Including GC basal medium, hemoglobin powder, VCNT bacteriostatic agent (including vancomycin, polymyxin, trimetho Benzylpyrimidine and nystatin), Iso-Vitalex booster.

2) Preparation method. Take the preparation of 500 mL medium as an example. The steps are as follows.

Weigh 18 g of GC agar powder, place it in a flask, add 235 mL of distilled water, shake it, and place in a boiling water bath for 15 min to 30 min.

Completely dissolve the agar;

Weigh 5 g of hemoglobin powder, add it to the mortar, dissolve it with 250 mL of distilled water, and place it in a boiling water bath for 15 min~ 30 min;

Autoclave the above two solutions at 121 ° C for 15 min, cool to 50 ° C, and hemoglobin under sterile conditions the solution is slowly added to the agar solution and the hemoglobin sediment that may be present is discarded;

Take 1 vial of Iso-Vitalex booster, dissolve it with a small vial of the attached vial and add to the mix of Step 3.

In the liquid mixture, shake it while adding it;

Take a small vial of VCNT bacteriostatic agent, dissolve it in 5 mL of sterile distilled water, and add to the mixture in step 4.

Add side to shake;

Dispense the prepared medium into a sterile dish under aseptic conditions. After solidification, seal it in a plastic bag and set at 4 °C.

The refrigerator is kept for use.

b) GC blood agar medium

1) Ingredients. Includes GC basal medium and defibrinated sheep blood.

2) Preparation method. Take 500 mL medium as an example, the steps are as follows.

Take 18 g of GC agar powder, place in a flask, add 450 mL of distilled water, shake well, and place in a boiling water bath for 15 min to 30 min.

Completely dissolve the agar;

Autoclave the GC agar solution at 121 ° C for 15 min and cool to 50 ° C;

Add 50 mL of defibrinated sheep blood (pregnancy of sheep blood in a 37 ° C water bath) to agar solution under aseptic conditions in the medium, shake it and place it in a sterile dish. After solidification, place it in a plastic bag and store it in a refrigerator at 4 °C.

c) Amies transport medium

1) Ingredients. Activated carbon 5 g, sodium chloride (NaCl) 1.5 g, disodium hydrogen phosphate (Na2HPO4) 0.575 g, potassium dihydrogen phosphate (KH2PO4) 0.1 g, potassium chloride (KCl) 0.1 g, sodium thioacetate 0.5 g, calcium chloride (CaCl) 0.05 g, magnesium chloride (MgCl) 0.05 g, 2 g of agar, 500 mL of distilled water.

2) Preparation method. Take 500 mL medium as an example, the steps are as follows.

Add the ingredients to 500 mL of distilled water and mix well;

Autoclave at 121 °C for 15 min, cool to 50 °C, then dispense into small tubes, 6 mL per tube. When dispensing, not Shake the agar while shaking so that the end of the activated carbon is in a uniform suspension state;

Store at 2 ° C ~ 8 ° C for 6 months.

A.2.2.2 Inoculated specimens Specimens should be inoculated as soon as possible after taking the samples. The medium should be pre-warmed at room temperature. Apply the swab of the material to the upper 1/4 of the plate the range is then lined with the inoculation loop to ensure a purer single colony.

A.2.2.3 Culture conditions Immediately after inoculation of the specimen, the plate was placed in an environment of (36 ± 1) ° C, containing 5% to 10% CO2, and moist (70% humidity). Drench Cocci are aerobic bacteria, but CO2 is required for primary separation. The CO2 environment can be supplied by a CO2 incubator, a CO2 gas bag or a candle cylinder. When using a candle jar, Use a white, non-fragrance, non-toxic candle. Place some soaked cotton balls at the bottom of the candle to maintain a certain humidity.

A.2.2.4 Observation results After 24 hours of culture, the plate should be inspected. At this time, the plate with no bacteria growth should be cultured for 72 hours. It can still be discarded after sterile growth.

Report of negative bacterial culture. Because some strains, such as AHU-nutrient strains, grow slowly and have small colonies. If the culture time is less than 72 h, They may be ignored. Suspected colonies isolated on selective media should be further identified.

A.2.2.5 Preliminary identification of Neisseria gonorrhoeae A.2.2.5.1 Colony characteristics. The size and morphology of the gonococcus colonies isolated on the selective medium may vary depending on the medium and the culture time.

Differences. In general, after growing for 24 h on a TM plate, the diameter is approximately 0.5 mm to 1 mm, which is round, convex, moist, smooth, and half.

Transparent or off-white colonies, usually sticky. After 48 hours of culture, the colony diameter can reach 3 mm, the edge is smooth or jagged, and the surface is rough.

A.2.2.5.2 Oxidase test. Neisseria gonorrhoeae has an oxidase that oxidizes an oxidase reagent to a quinone compound and exhibits a color reaction. Jian the matters are as follows.

a) Reagents. Including tetramethyl-p-phenylenediami...