PREVALENCE OF GONOCOCCAL INFECTION AMONG THE PATIENTS VISITING AT DERMATOLOGY/VENEROLOGY AND GYNAECOLOGY DEPARTMENT OF TRIBHUVAN UNIVERSITY TEACHING HOSPITAL

A substantial proportion of women with gonococcal infection are asymptomatic but symptomatic in male. Thus in developing countries, problem arises in active case detection where laboratory facilities for testing are limited. During the study, the diagnostic validity of the hierarchial clinical algorithm as well as that of a nonhierarchial scoring system were assessed among 102 patient visiting at Dermatology/ Venerology (DV) and Gynecology(Gynae) out patient department(OPD) of Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal. In the study period of 8 months, May –December 1999, 9 (8.82%) were infected with N. gonorrhoea & 2(1.96%) with Gram Negative intracellular diplococci. Age group of 20-30 years were found to be more infected followed by age groups 30-40 years & 40-50 years ( P< 0.10). The male were found to be predominantly infected than female and married were found to be more infected than unmarried. Among the infected people most of them had secondary level education and least of them had higher level education. Service holders were found to be more infected than farmers, drivers & others. But male service holders & housewives were equally infected. Antimicrobial susceptibility of N. gonorrhoea showed 100% susceptible to Ceftriaxone, followed by Ciprofloxacin (88.88%) whereas 22.22% resistant to Tetracycline, 55.55% to Cotrimoxazole and 55.55% to Penicillin. Among isolates, 33.33% were ßlactamase producer. Co-micro organisms like Candida spp and Staphylococcus spp were also observed. 1. Research Officer, Infectious and Tropical Disease Research Centre, Tripureshwor, Kathmandu, Nepal. 2. Associate Professor, Head of Department, Clinical Microbiology, Institute of Medicine, TUTH, Nepal. 3. Professor, Central Department of Microbiology, Kirtipur, Kathmandu, Nepal. 4. Associate Professor, Department of Obstetrics/ Gynecology Department, Institute of Medicine, TUTH, Nepal. 5. Assistant Professor , Head of Dept., Dermatologist, Venerologist & Leprologist, Dept. of Dermatology/Venerology, Institute of Medicine, TUTH, Nepal. Address for correspondence : Binita Panta, Research Officer, Infectious and Tropical Disease Research Centre, Tripureshwor, Kathmandu, Nepal. P.O. Box: 8973, NPC 565 Tel: 493680 (Res.), Email: gyan@col.com.np ORIGINAL ARTICLE Journal of Nepal Medical Association, 2001:40:12-17 Panta B, Tuladhar N R Sharma A P, Sharma J, Jha A K


INTRODUCTION
The term "Gonorrhoea" was first derived from the Latin word (Gono = pus-like, rrhoea = discharge).Gonorrhoea has history stretching back into antiquity and entirely ignorant of the time and place of its first appearance.But it is mentioned many times in biblical writings.The causative organisms Neisseria gonorrhoea was discovered in 1879 by Neisser. 1 Among the Sexually Transmitted Diseases (STDs), gonorrhoea is a common cause of illness in the world and have far reaching health, social and economic consequences.In addition to their sheer magnitude, gonorrhoea is a major public health problem for two additional reasons: its serious sequelae and the fact that they facilitate transmission of HIV.The STDs, like gonorrhoea is mainly transmitted through sexual contact and sometimes from mother to child before or during birth.It generally affects the male & female reproductive tract and sometimes eyes in case of neonates, leading to blindness. 2cent WHO estimate put the number of new case of gonorrhoea world wide at 62 million annually. 3ccording to result of DV department of TUTH, 32% of N. gonorrhoea were detected. 4Despite a substantial decrease in the incidence of gonorrhoea in western countries in the past decade, a major burden of gonococcal disease remains in less developed countries and amongst the socially marginalized in the developed world. 5Control of gonococcal disease in made more difficult due to the emergence of drug resistant strains, so a programme on surveillance of antimicrobial susceptibility in N. gonorrhoea should also be taken as an integral part of a routine test .Although early diagnosis and treatment could prevent these complication, as gonococcal infection is asymptomatic in women and many infected women fail to seek healthcare.

METHODOLOGY
Between May 1999 to December 1999, N. gonorrhoea were isolated from the 102 patients attending DV and gyanae OPD of TUTH, Kathmandu (Male: 20 & Female: 82) As most of woman have asymptomatic infection, woman complaining with vaginal discharge, burning micturation, lower abdominal pain, infertility, stillbirth, back pain etc. were enrolled in the study to trace out if causal organisms is gonococcus or not.Male presenting with pus discharge, or watery, sticky discharge, burning & urgency of micturation, prepusal swelling or any complain in genital organ with discharge were included.Then direct queries were done in order to get all the necessary information required for the study.In case of female, endo-cervical swabs and in case of male, urethral swabs were taken and streaked on modified Thayer Martin (TM ) Agar and on Chocolate Agar (CA).Also smears were prepared on glass slide for gram staining.The identification of the organisms was confirmed by colony morphology, gram staining, oxidase test & catalase tests.Further re-comfirmed by inoculation in Nutrient Agar where no growth was observed as recommended by. 6tibiotic sensitivity test was performed by Kirby Bauer Disc Diffusion method modified by NCCLS 1995, 6 where antimicrobial disc containing penicillin (10 U disc) Tetracycline (30 mg), Ciprofloxacin (5 mg), Ceftriaxone (30 mg) and Cotrimoxazole (25 mg) were used (all from oxoid, Hamphire U.K.) and the zone of inhibition was interpreted according to NCCLS. 7All penicillinresistant isolates were tested for ß-lactamase production by chromogenic cephalosporin method.

RESULTS
Among the endo-cervical swabs and urethral swabs (n = 102), 9 (8.82%) were culture positive for N. gonorrhoea & 2 (1.96%) Gram negative diplocococci but negative in culture and 34 (31.19%)cases showed the presence of pus cells in microscopic examination.Age group of 20-30 years were found to be more infected (55.55%) followed by age group 30-40 years (22.22%) and age group 40-50 years (22.22%).Male were found to be more infected in comparison to female and infection rate was found to be high among the married people.Housewives and service holders were most common suffers and regarding their partner most of them were housewives and farmers followed by service holders and others.
Table II: Patients' Complaints (n=102) In the study the highest study population have had lower abdominal pain followed by other complains whereas lowest study population have had complain of infertility and swelling of prepuce.
The study showed that the Ceftriaxone was 100% susceptible where as Penicilline was least effective.

DISCUSSION
Sexually transmitted diseases take a great roll on health through their sequelae, i.e. conditions resulting from the spread of STD pathogens from the point of infection usually to another part of reproductive tract, such as the fallopian tubes in women.Sequelae of some STDs is Pelvic Inflammatory Disease (PID), which is a common serious complication of N. gonorrhoea and Chlamydia trachomatis, tubal disease, infertility, chronic pain and disability requiring multiple hospitalization and surgery.  2 In many western countries, incidence of gonorrhoea has declined since the mid-1970s; during the past year, however, evidence that the incidence of gonorrhoea is on the increase again in these countries, as in the developing countries, has emerged.Similarly prevalence rate of gonorrhoea was 10% in Bottambay which is comparable to our study and varied in 39% in Sisophan 8 and 9% of woman had a GC positive with moderate PID. 9 As the years passes on, there is gradual change in socio-economy status of each countries, which rules the public health.This change in socio-economic status could be the cause of difference of findings of some other's of study.The data shows that resistant to commonly used antimicrobial agents have increased and consequently penicillin & tetracycline can no longer be recommended for the treatment of gonococcus.Surveillance is an integral part of controlling resistance.A co-ordinated multidisciplinary approach is required to tackle this problem.Prevention and control of emergence and dissemination of antimicrobial resistant organism must be establish as a strategic priority for international and national public health agencies as well as for individual institutions and health care practitioners.