INTRODUCTION — Perinatal acquisition of sexually transmitted infections can have serious consequences for the newborn. Ophthalmia neonatorum (newborn conjunctivitis) was caused principally by Neisseria gonorrhoeae at one time in the United States and was the most common cause of blindness. Although this newborn infection has decreased in frequency throughout the world, the consequences of untreated disease remain grave.
Gonococcal infection in the newborn is reviewed here. The epidemiology and pathogenesis of N. gonorrhoeae infection are discussed separately. (See "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection".)
Neonatal infection with other sexually transmitted organisms is discussed separately:
●(See "Chlamydia trachomatis infections in the newborn".)
●(See "Congenital syphilis: Management and outcome".)
●(See "Neonatal herpes simplex virus infection: Clinical features and diagnosis" and "Neonatal herpes simplex virus infection: Management and prevention".)
●(See "Hepatitis viruses and the newborn: Clinical manifestations and treatment".)
●(See "Diagnostic testing for HIV infection in infants and children younger than 18 months".)
EPIDEMIOLOGY — The incidence of neonatal gonococcal infection relates to the prevalence of infection among women of childbearing age, which varies somewhat worldwide. In resource-rich regions, the prevalence of gonococcal infection among pregnant women is <1 percent; the prevalence in resource-limited settings is considerably higher. (See "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Global incidence'.)
In pregnant women, coinfection with Chlamydia trachomatis is common and HIV transmission is heightened in the presence of gonorrhea [1-3]. (See "Epidemiology of Chlamydia trachomatis infections" and "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Association with HIV'.)
In the newborn, the eye is the most frequent site of gonococcal infection [4]. (See 'Ophthalmia neonatorum' below.)
The epidemiology of N. gonorrhoeae infection is discussed in greater detail separately. (See "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Epidemiology'.)
PERINATAL TRANSMISSION — Newborns typically acquire gonococcal infection during delivery. Perinatal transmission occurs in 30 to 40 percent of cases of maternal cervical infection in the United States [5]. Intrauterine infection also can occur after rupture of the membranes.
Association with prematurity — Untreated maternal gonococcal disease appears to increase the risk of preterm delivery [6]. Reported rates of prematurity range from 13 to 67 percent, although most studies include relatively few patients and provide little information on associated conditions or concurrent infections [7-12].
In a case-control study that included 166 cases and 175 controls who were evaluated for sexually transmitted infections, the attributable risk of preterm birth associated with gonococcal infection was 14 percent [6]. The association with prematurity appeared to be specific for gonococcal infection and was not found for other sexually transmitted infections.
OPHTHALMIA NEONATORUM — The eye is the most frequent site of gonococcal infection in the newborn. As noted above, gonococcal infection is a rare, although serious, cause of ophthalmia neonatorum in developed countries due in large measure to the use of routine prophylaxis.
Clinical features — Infection typically causes a purulent conjunctivitis, with profuse exudate and swelling of the eyelids (picture 1). Without treatment, the infection can extend from the superficial epithelial layers into the subconjunctival connective tissue and the cornea, leading to ulceration, scarring, and visual impairment.
The infection usually becomes manifest two to five days after birth. However, factors including ophthalmic prophylaxis, inoculum size, or variations in virulence may result in a more indolent course and delay in onset.
Diagnosis — Ophthalmia neonatorum is confirmed by a positive culture of exudate for N. gonorrhoeae in a newborn with conjunctivitis. Neonates who develop conjunctivitis after the first day of age or appear to have severe or persistent chemical conjunctivitis should be evaluated. A Gram stain of the conjunctival exudate should be examined for the presence of typical gram-negative intracellular kidney bean-shaped diplococci. Caution should be used in interpreting the Gram stain results since other nonpathogenic Neisseria species can be mistaken for N. gonorrhoeae [1]. Culture of the exudate should be performed using selective media (eg, modified Thayer-Martin medium) that inhibit normal flora and nonpathogenic Neisseria organisms. Cultures from other sites (eg, oropharyngeal and rectal swabs) can also be helpful in confirming the diagnosis.
Additional evaluation — Newborns with conjunctivitis should be evaluated for C. trachomatis. Coinfection with this organism is common with gonococcal disease. (See "Chlamydia trachomatis infections in the newborn".)
The infant's mother and her sexual partner(s) should be evaluated and treated for gonococcal infection (see "Treatment of uncomplicated Neisseria gonorrhoeae infections"). She also should be evaluated for other sexually transmitted infections, including HIV infection.
Differential diagnosis — Other causes of purulent conjunctivitis in newborns include other bacteria (eg, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, C. trachomatis) and viral infections (eg, adenovirus, herpes simplex virus). Noninfectious causes of neonatal conjunctivitis include chemical conjunctivitis (caused by prophylactic eye drops or ointment) and dacryostenosis; however, these latter causes typically are not associated with purulent eye discharge. The timing of onset and clinical findings can help distinguish N. gonorrhoeae from other causes of neonatal conjunctivitis (N. gonorrhoeae infection typically presents two to five days after birth and is characterized by profuse exudate and swelling of the eyelids (picture 1)). However, Gram stain and culture are necessary to make the diagnosis. (See "Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele" and "Conjunctivitis".)
N. gonorrhoeae is a rare cause of neonatal conjunctivitis in areas of the world where ophthalmologic prophylaxis is routine. In one series of 332 neonates with conjunctivitis, one-half had no pathogen detected. The most common bacterial pathogens were H. influenzae (17 percent), S. pneumoniae (12 percent), S. aureus (9 percent), and C. trachomatis (8 percent); no cases of gonococcal infection were identified [13]. In other series, S. aureus was the most common pathogen and N. gonorrhoeae and C. trachomatis were responsible for <5 percent of cases [14,15].
Treatment — Treatment of neonatal N. gonorrhoeae conjunctivitis consists of a single dose of ceftriaxone (25 to 50 mg/kg, not to exceed 125 mg, intravenously or intramuscularly) [2]. Ceftriaxone should be used with caution in infants with clinically significant hyperbilirubinemia (since it displaces bilirubin from albumin and may increase the risk of encephalopathy), and it should be avoided in neonates receiving calcium-containing intravenous fluids including parenteral nutrition (due to risk of precipitation). Alternative agents that can be used in these circumstances include cefotaxime (if available) or ceftazidime [1,16,17]. Topical antibiotic therapy alone is inadequate and is not necessary when systemic treatment is provided [1]. The eyes should be irrigated frequently with saline until the discharge clears.
Infants with gonococcal ophthalmic disease should be hospitalized and observed for response to therapy and for disseminated disease. Presumptive treatment should be started after obtaining cultures in infants with organisms seen on Gram stain or in those with negative Gram stain but who are considered to be at high risk (eg, mother with no prenatal care, history of sexually transmitted infections, or substance abuse).
Prevention — The most effective measure to prevent both gonococcal and chlamydial infections is to diagnosis and treat these infections in pregnant women. In addition, prophylactic antibiotic eye therapy reduces the risk of gonococcal conjunctivitis; however, it is not effective in preventing C. trachomatis conjunctivitis.
●Maternal screening – Screening for gonorrhea during pregnancy is discussed separately. (See "Prenatal care: Initial assessment", section on 'Gonorrhea'.)
●Neonatal prophylaxis – The risk of contracting gonococcal conjunctivitis is markedly reduced by effective prophylaxis [18,19]. Prophylaxis can be deferred for up to one hour after birth to facilitate infant-family attachment. The following are regimens recommended by the American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the United States Preventive Services Task Force [1,2,20]:
•Erythromycin (0.5%) ophthalmic ointment
•Tetracycline (1%) ophthalmic ointment; tetracycline ophthalmic ointment is not available in the United States
Prophylaxis for gonococcal conjunctivitis is discussed in greater detail separately. (See "Overview of the routine management of the healthy newborn infant", section on 'Eye care'.)
OTHER LOCALIZED INFECTION — In addition to conjunctivitis, localized infection of other mucosal surfaces can occur. The pharynx, vagina, urethra, and anus can be affected [21]. Scalp abscesses may result from infection introduced by a fetal monitoring electrode [22]. Neonates with a scalp abscess or in whom sepsis is suspected should be treated for disseminated infection. (See 'Treatment' below.)
Diagnostic evaluation consists of cultures from the affected site, blood, and cerebrospinal fluid (CSF) to make certain that the infection has not spread. With the exception of scalp abscess, which is treated in the same manner as disseminated disease, most localized infections can be treated with a single dose of ceftriaxone (25 to 50 mg/kg, not to exceed 125 mg, administered intravenously or intramuscularly) or cefotaxime (if available; 100 mg/kg, administered intravenously or intramuscularly).
DISSEMINATED INFECTION AND SCALP ABSCESS — Disseminated disease may present as sepsis, arthritis, or meningitis. Septic arthritis is the most common manifestation of disseminated disease [23-25]. Gonococcal bacteremia and/or meningitis are rare in the newborn but can be a complication of ophthalmia neonatorum and other localized infections, particularly scalp abscess [5,26].
Clinical features — The clinical features vary depending on the type of infection:
●Sepsis – The signs and symptoms of neonatal sepsis are nonspecific. They are summarized in the table and are discussed in greater detail separately (table 1). (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm neonates", section on 'Clinical manifestations'.)
●Meningitis – Common presenting signs and symptoms include fever, irritability, lethargy, vomiting, and poor feeding. The clinical features of neonatal meningitis are discussed in greater detail separately. (See "Bacterial meningitis in the neonate: Clinical features and diagnosis", section on 'Clinical features'.)
●Arthritis – Gonococcal arthritis typically presents at 2 to 21 days of age. The infant may appear only mildly to moderately ill, and the temperature may be normal or slightly elevated [25]. Multiple joints usually are affected. The infant typically refuses to move the painful, affected limb. (See "Bacterial arthritis: Clinical features and diagnosis in infants and children".)
●Scalp abscess – Infection can occur in infants who underwent fetal scalp electrode placement prior to delivery if the mother had an unknown or untreated infection [22,27]. Necrosis and scalp abscess can occur, which is associated with a high risk of disseminated infection.
Diagnosis — Diagnosis of disseminated infection is confirmed by a positive culture for N. gonorrhoeae from blood, cerebrospinal fluid (CSF), or synovial fluid.
Cultures should be obtained of blood and CSF in all infants with suspected disseminated infection. For neonates with signs and symptoms of arthritis, synovial fluid should be aspirated from an affected joint and Gram stain and culture obtained. For neonates with scalp abscess, cultures of the site should be obtained in addition to blood and CSF cultures. Specimens obtained from the conjunctiva, vagina, oropharynx, and rectum are useful for identifying the primary site(s) of infection. A positive Gram stain of exudate, CSF, or joint aspirate provides a presumptive basis for initiating treatment [2].
Treatment — Treatment of disseminated infection consists of ceftriaxone (25 to 50 mg/kg per dose once daily intravenously or intramuscularly) [1,2,28]. The duration of treatment is seven days for septicemia, arthritis, or scalp abscess and 10 to 14 days for meningitis [1].
Ceftriaxone should be avoided in the following settings:
●Infants with clinically significant hyperbilirubinemia (since it displaces bilirubin from albumin and may increase the risk of encephalopathy)
●Preterm neonates (due to increased risk of hyperbilirubinemia/encephalopathy)
●Infants receiving calcium-containing intravenous fluids including parenteral nutrition (due to risk of precipitation)
Alternative agents that can be used in these circumstances include cefotaxime (if available) or ceftazidime [1,16,17].
Other classes of antibiotics (eg, macrolides, fluoroquinolones) should not be used, because of high resistance rates. N. gonorrhoeae drug resistance is discussed in detail separately. (See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on 'Antibiotic resistance'.)
ASYMPTOMATIC INFANTS OF UNTREATED MOTHERS — Asymptomatic infants whose mothers have untreated gonococcal infection are at high risk for acquiring infection. These infants also should receive systemic treatment with a single dose of one of the following [1,2]:
●Ceftriaxone 25 to 50 mg/kg, up to a total dose of 125 mg, administered intravenously or intramuscularly, or
●Cefotaxime (if available) 100 mg/kg, administered intravenously or intramuscularly, or
●Ceftazidime 50 mg/kg, administered intravenously or intramuscularly
In addition, the neonate should be evaluated for chlamydial infection [2]. (See "Chlamydia trachomatis infections in the newborn", section on 'Diagnosis'.)
SUMMARY AND RECOMMENDATIONS
●Transmission – Newborns acquire gonococcal infection during delivery. The perinatal transmission rate is approximately 30 to 40 percent in women with cervical infection. (See 'Perinatal transmission' above.)
●Ophthalmia neonatorum – In the newborn, the eye is the most frequent site of gonococcal infection (see 'Ophthalmia neonatorum' above):
•Gonococcal ophthalmia neonatorum is characterized by a purulent conjunctivitis with profuse exudate and swelling of the eyelids. Without treatment, the infection can extend from the superficial epithelial layers into the subconjunctival connective tissue and the cornea, leading to ulceration, scarring, and visual impairment. The diagnosis is confirmed by culture of the exudate. (See 'Clinical features' above and 'Diagnosis' above.)
•The incidence of gonococcal ophthalmia neonatorum has decreased with the use of routine antibiotic prophylaxis and maternal screening for sexually transmitted infections. (See 'Prevention' above.)
•For treatment of gonococcal conjunctivitis in neonates, we suggest treatment with a single dose of ceftriaxone rather than topical therapy (Grade 2C). Ceftriaxone can be administered intravenously or intramuscularly at a dose of 25 to 50 mg/kg, not to exceed 125 mg. Ceftriaxone should generally be avoided in preterm neonates, infants with clinically significant hyperbilirubinemia, and neonates receiving calcium-containing intravenous fluids. Alternative agents that can be used in these circumstances include cefotaxime (where available) or ceftazidime. The infant should be hospitalized and observed for response to therapy and for disseminated disease. Infants with confirmed gonococcal disease should also be evaluated for coinfection with Chlamydia trachomatis. (See 'Treatment' above and 'Additional evaluation' above.)
●Other localized infections – Localized infection of other mucosal surfaces can occur, including the pharynx, vagina, urethra, and anus. For treatment of these infections in the absence of signs of disseminated disease, we suggest a single dose of ceftriaxone (Grade 2C). (See 'Other localized infection' above.)
●Disseminated disease – Disseminated disease may present as sepsis, arthritis, or meningitis (see 'Disseminated infection and scalp abscess' above):
•Septic arthritis is the most common manifestation of disseminated disease. Gonococcal bacteremia and/or meningitis are rare in the newborn but can be a complication of ophthalmia neonatorum and other localized infections, particularly scalp abscesses. (See 'Clinical features' above.)
•For treatment for disseminated infection, we suggest ceftriaxone rather than other agents (Grade 2C). Ceftriaxone can be administered intravenously or intramuscularly at a dose of 25 to 50 mg/kg per dose given once daily. The duration of treatment is seven days for septicemia, arthritis, or scalp abscess and 10 to 14 days for meningitis. Ceftriaxone should generally be avoided in preterm neonates, infants with clinically significant hyperbilirubinemia, and neonates receiving calcium-containing intravenous fluids. Alternative agents that can be used in these circumstances include cefotaxime (where available) or ceftazidime. (See 'Other localized infection' above and 'Disseminated infection and scalp abscess' above.)
●Asymptomatic infants – For asymptomatic infants whose mothers have untreated gonococcal infection, we suggest treatment with a single dose of ceftriaxone (Grade 2C). (See 'Asymptomatic infants of untreated mothers' above.)
