Characterizing the Rise of Disseminated Gonococcal Infections in California, July 2020–July 2021

Abstract

Background California has experienced an increase in reported cases of disseminated gonococcal infection (DGI). Given significant morbidity associated with DGI and the ability of Neisseria gonorrhoeae to rapidly develop antibiotic resistance, characterizing these cases can inform diagnosis, management, and prevention of DGI. Methods As part of the public health response to increased reports of DGI, we used gonorrhea surveillance data reported to the California Department of Public Health (CDPH) to identify all DGI cases in a geographically-bound region. Standardized case report forms were used to collect epidemiologic risk factors and clinical information obtained from provider/laboratory report, medical records, and patient interviews. Results From July 1, 2020 to July 31, 2021, we identified 149 DGI patients among 63,338 total gonorrhea infections reported to CDPH, representing 0.24% of gonorrhea cases. Estimated incidence was 0.47 DGI cases per 100,000 person-years. Mean age of DGI patients was 40 years, and 75 (50%) were cisgender men, of whom only 13 were known to have male partners. Where reported, over a third (36%) used methamphetamine and nearly a quarter (23%) experienced homelessness. Clinically, 61% lacked urogenital, pharyngeal, or rectal symptoms; 2 patients died in the hospital. Among 47 isolates from patients with antimicrobial susceptibility testing (AST) results available, all were susceptible to ceftriaxone and cefixime. Conclusions Most DGI patients lacked urogenital symptoms and were not among populations for which routine gonorrhea screening is currently recommended. Expanding gonorrhea screening might prevent DGI. Cefixime is likely the best option if transitioning from parenteral to oral therapy when AST results are not available.

Disseminated Gonococcal Infections—Lessons Learned From an Ongoing California Public Health Investigation

“…They may also lack the urogenital symptoms 2 that might otherwise prompt consideration of a gonorrhea diagnosis (such symptoms have been absent in the majority of CA DGI cases 1 ). Further complicating the picture, although current routine STI screening recommendations focus primarily on people younger than 25 years and men who have sex with men, 10 most CA DGI cases have instead occurred among older individuals aged 30 to 50 years (median age, 40 years 1 ), the majority of whom identified as heterosexual (and thus may not have been considered for routine gonorrhea screening). For these reasons, both disseminated and mucosal-site gonococcal infections may go initially undetected in DGI patients.…”

“…Disseminated gonococcal infections (DGI) occur when the sexually transmitted pathogen Neisseria gonorrhoeae invades the bloodstream and travels to distant sites of the body, 1 resulting in manifestations including dermatitis, migratory polyarthritis, tenosynovitis, bacteremia, septic arthritis, endocarditis, meningitis, osteomyelitis, and others. DGI is a significant public health concern, with the potential to cause serious morbidity and even mortality 2,3 .…”

“…DGI is a significant public health concern, with the potential to cause serious morbidity and even mortality. 2,3 Although DGI has been considered historically rare (estimated to result from just 0.5% to 3% of untreated gonorrhea infections), 1,4,5 the California Department of Public Health (CDPH) Sexually Transmitted Diseases (STD) Control Branch has recently observed an increase in reported DGI cases 1 in the context of increases in gonococcal infections overall (which rose by 48.8% between 2015 and 2019 6 ). Between July 2020 and mid-May 2022, over 200 California (CA) DGI cases (including 4 deaths) have been reported to CDPH, prompting an ongoing statewide public health investigation.…”

“…Details of our investigation, along with the clinical/ epidemiologic characteristics of CA DGI cases, have been described elsewhere. 1,7 The purpose of this commentary is instead to share clinical, disease investigation, and surveillance/epidemiology "lessons learned" based on CDPH's recent experience responding to DGI. Since other jurisdictions may soon experience increases in DGI-particularly considering national increases in reported gonorrhea cases (which rose 45% between 2016 and 2020 8 ), combined with purported COVID-19-related decreases in screening, testing, and treatment for sexually transmitted infections (STIs) 9 our goals are to help clinicians, public health professionals, and STD programs better: (1) recognize the variable clinical manifestations of DGI, (2) appropriately manage DGI patients and their sex partners, and (3) detect DGI cases using existing STD surveillance data.…”

“…Details of our investigation, along with the clinical/epidemiologic characteristics of CA DGI cases, have been described elsewhere 1,7 . The purpose of this commentary is instead to share clinical, disease investigation, and surveillance/epidemiology “lessons learned” based on CDPH's recent experience responding to DGI.…”