Gonococcal Infections Among Neonates

Prenatal screening and treatment of pregnant women for gonorrhea is the best method for preventing N. gonorrhoeae infection among neonates. Gonococcal infection among neonates results from perinatal exposure to the mother’s infected cervix. It is usually an acute illness that manifests 2–5 days after birth. Prevalence of infection among neonates depends on the prevalence of infection among pregnant women and whether pregnant women are screened and treated for gonorrhea during pregnancy. The most severe manifestations of N. gonorrhoeae infection among neonates are ophthalmia neonatorum and sepsis, which can include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and scalp infection at sites of previous fetal monitoring.

Preventing Ophthalmia Neonatorum Caused by N. gonorrhoeae

Ocular prophylaxis and preventive gonorrhea screening and treatment of infected pregnant women are especially important because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness (903). Ocular prophylaxis for gonococcal ophthalmia neonatorum has a long history of preventing sight-threatening gonococcal ocular infections. Cases in the United States are uncommon, which is likely attributable to gonorrhea screening programs for women, including pregnant women, that have contributed substantially to reduction in ophthalmia neonatorum (904). Neonatal ocular prophylaxis with erythromycin, the only agent available in the United States, is required by law in most states and is recommended because of safety, low cost, and ease of administration. It can contribute to preventing gonococcal blindness because not all pregnant women are screened for gonorrhea. The USPSTF recommends ocular prophylaxis with erythromycin ointment for all newborns <24 hours after birth (903). In addition to continuing routine ocular prophylaxis, prevention should focus on prenatal screening for N. gonorrhoeae, including

  • screening pregnant women at risk (e.g., women aged <25 years and those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, a sex partner who has an STI, or live in a community with high rates of gonorrhea) for N. gonorrhoeae infection at the first prenatal visit;
  • treating all pregnant women with N. gonorrhoeae infection during pregnancy and retesting in 3 months, in the third trimester or at time of delivery (sex partners should be tested and treated);
  • retesting pregnant women in the third trimester who initially tested negative but remained at increased risk for acquiring infection (e.g., women aged <25 years and those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, a sex partner who has an STI, or live in a community with high rates of gonorrhea); and
  • screening for gonorrhea at delivery for women not tested during pregnancy and at risk for infection (e.g., women aged <25 years and those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, a sex partner who has an STI, or live in a community with high rates of gonorrhea) or received no prenatal care; providers caring for the mother and the newborn should communicate to ensure follow-up on the results of laboratory tests performed at delivery, and if positive, prompt appropriate treatment of the newborn and mother.

Erythromycin is the only ophthalmic ointment recommended for use among neonates. Silver nitrate and tetracycline ophthalmic ointments are no longer manufactured in the United States, bacitracin is ineffective, and povidone iodine has not been studied adequately (905,906). Gentamicin ophthalmic ointment has been associated with severe ocular reactions (907,908). If erythromycin ointment is unavailable, infants at risk for exposure to N. gonorrhoeae, especially those born to a mother at risk for gonococcal infection or with no prenatal care, can be administered ceftriaxone 25–50 mg/kg body weight IV or IM, not to exceed 250 mg in a single dose.

Recommended Regimen to Prevent Ophthalmia Neonatorum Caused by N. gonorrhoeae

Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth

Erythromycin ophthalmic ointment should be instilled into both eyes of neonates as soon as possible after delivery, regardless of whether they are delivered vaginally or by cesarean delivery. Ideally, ointment should be applied by using single-use tubes or ampules rather than multiple-use tubes. If prophylaxis is delayed (i.e., not administered in the delivery room), a monitoring system should be established to ensure that all newborns receive prophylaxis <24 hours after delivery.

Diagnostic Considerations

Newborns at increased risk for gonococcal ophthalmia include those who did not receive ophthalmic prophylaxis and whose mothers had no prenatal care, have a history of STIs during pregnancy, or have a history of substance misuse. Gonococcal ophthalmia is strongly suspected when intracellular gram-negative diplococci are identified on Gram stain of conjunctival exudate, justifying presumptive treatment for gonorrhea after appropriate cultures and antimicrobial susceptibility testing for N. gonorrhoeae are performed. Presumptive treatment for N. gonorrhoeae might be indicated for newborns at increased risk for gonococcal ophthalmia who have increased WBCs (no GNID) in a Gram-stained smear of conjunctival exudate. Nongonococcal causes of neonatal ophthalmia include Moraxella catarrhalis and other Neisseria species, which are organisms that are indistinguishable from N. gonorrhoeae on Gram-stained smear but can be differentiated in the microbiology laboratory.

Treatment of Gonococcal Ophthalmia Neonatorum

Recommended Regimen for Gonococcal Ophthalmia Neonatorum

Ceftriaxone 25–50 mg/kg body weight IV or IM in a single dose, not to exceed 250 mg

One dose of ceftriaxone is adequate therapy for gonococcal ophthalmia. Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely. Cefotaxime 100 mg/kg body weight IV or IM as a single dose can be administered for those neonates unable to receive ceftriaxone because of simultaneous administration of IV calcium. Topical antibiotic therapy alone is inadequate and unnecessary if systemic treatment is administered.

Other Management Considerations

Chlamydial testing should be performed simultaneously from the inverted eyelid specimen (see Ophthalmia Neonatorum Caused by C. trachomatis). Newborns who have gonococcal ophthalmia should be evaluated for signs of disseminated infection (e.g., sepsis, arthritis, and meningitis). Newborns who have gonococcal ophthalmia should be managed in consultation with an infectious disease specialist.

Management of Mothers and Their Sex Partners

Mothers of newborns with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partners (see Gonococcal Infection Among Adolescents and Adults).

Disseminated Gonococcal Infection and Gonococcal Scalp Abscesses Among Neonates

DGI might present as sepsis, arthritis, or meningitis and is a rare complication of neonatal gonococcal infection. Localized gonococcal infection of the scalp can result from fetal monitoring through scalp electrodes. Detecting gonococcal infection among neonates who have sepsis, arthritis, meningitis, or scalp abscesses requires cultures of blood, CSF, or joint aspirate. Specimens obtained from the conjunctiva, vagina, oropharynx, and rectum are useful for identifying the primary site or sites of infection. Antimicrobial susceptibility testing of all isolates should be performed. Positive Gram-stained smears of abscess exudate, CSF, or joint aspirate provide a presumptive basis for initiating treatment for N. gonorrhoeae.

Treatment

Recommended Regimens for Disseminated Gonococcal Infection Among Neonates

Ceftriaxone 25–50 mg/kg body weight/day IV or IM in a single daily dose for 7 days, with a duration of 10–14 days if meningitis is documented

OR

Cefotaxime 25 mg/kg body weight/day IV or IM every 12 hours for 7 days, with a duration of 10–14 days if meningitis is documented

Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely. Cefotaxime 100 mg/kg body weight IV or IM as a single dose can be administered for those neonates unable to receive ceftriaxone because of simultaneous administration of IV calcium.

Other Management Considerations

Chlamydial testing should be performed simultaneously among neonates with gonococcal infection (see Chlamydial Infection Among Neonates). Neonates who have DGI should be managed in consultation with an infectious disease specialist.

Management of Mothers and Their Sex Partners

Mothers of newborns who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partners (see Gonococcal Infection Among Adolescents and Adults).

Neonates Born to Mothers Who Have Gonococcal Infection

Neonates born to mothers who have untreated gonorrhea are at high risk for infection. Neonates should be tested for gonorrhea at exposed sites (e.g., conjunctiva, vagina, rectum, and oropharynx) and treated presumptively for gonorrhea.

Treatment in the Absence of Signs of Gonococcal Infection

Recommended Regimen for Neonates Without Signs of Gonococcal Infection

Ceftriaxone 20-50 mg/kg body weight by IV or IM in a single dose, not to exceed 250 mg

Other Management Considerations

Ceftriaxone should be administered cautiously to neonates with hyperbilirubinemia, especially those born prematurely. Cefotaxime 100 mg/kg body weight IV or IM as a single dose can be administered for those neonates unable to receive ceftriaxone because of simultaneous administration of IV calcium. Age-appropriate chlamydial testing should be performed simultaneously among neonates with gonococcal infection (see Chlamydial Infection Among Neonates). Follow-up examination is not required.

Management of Mothers and Their Sex Partners

Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea (see Gonococcal Infection Among Adolescents and Adults).