94: Gonorrhea

Infection with Neisseria gonorrhoeae (a Gram-negative oxidase-positive diplococcus) is a reproductive tract infection that is an important infection in pregnancy because of transmission to the fetus or neonate.

In 2010, the reported rate of gonorrhea in the United States was ∼ 1 per 1000. The incidence is highest in females 15 through 24 years of age. If routine ophthalmic prophylaxis was not used, it is estimated that a third of newborn infants born to infected mothers would become infected.

Neisseria gonorrhoeae primarily affects the endocervical canal of the mother. The infant may become infected during passage through an infected cervical canal or by contact with contaminated amniotic fluid if rupture of membranes has occurred. Coinfection with Chlamydia trachomatis is frequent, and human immunodeficiency virus (HIV) transmission is enhanced in the presence of gonorrhea.

1. Ophthalmia neonatorum (neonatal conjunctivitis). The most common clinical manifestation is gonococcal ophthalmia neonatorum. This occurs in 1–2% of cases of positive maternal gonococcal infection despite appropriate eye prophylaxis. For a description of this disease, see Chapter 53.

2. Gonococcal arthritis. The onset of gonococcal arthritis can occur at any time from 1–4 weeks after delivery. It is secondary to gonococcemia. The source of bacteremia has been attributed to infection of the mouth, nares, and umbilicus. The most common sites are the knees and ankles, but any joint may be affected. The infant may present with mild or moderate symptoms. Drainage of affected joint and antibiotics are mandatory.

3. Amniotic infection syndrome. Occurs when there is premature rupture of membranes, with inflammation of the placenta and umbilical cord. The infant may have clinical evidence of sepsis. This infection is associated with a high mortality rate.

4. Sepsis and meningitis. See Chapters 130 and 109, respectively.

5. Scalp abscess. Usually secondary to intrauterine fetal monitoring.

6. Other localized infections. Other infections involving mucus membranes like the pharynx, vagina, urethra, and anus has been described.

1. Mother. Endocervical scrapings should be obtained for culture.

2. Infant

   1. Gram stain. Gram stain of any exudate should be performed.

   2. Culture. Material may be obtained by swabbing the eye or nasopharynx or the orogastric or anorectal areas. Blood should be obtained for culture. Cultures for concomitant infection with Chlamydia trachomatis should also be done. Gonococcal cultures from nonsterile sites (eg, the pharynx, rectum, and vagina) should be done using selective media.

   3. Lumbar puncture with spinal fluid studies. Cell count, protein, culture, Gram stain, and others should be ordered.

Isolation precautions for all infectious diseases, including maternal and neonatal precautions, breast-feeding, and visiting issues, can be found in Appendix F.

1. Hospitalization. Infants with clinical evidence of ophthalmia neonatorum, scalp abscess, or disseminated infection should be hospitalized. Complete sepsis evaluation including lumbar puncture should be performed. Tests for concomitant C. trachomatis, congenital syphilis, and HIV infection should be done. Results of the maternal tests for hepatitis B surface antigen should be confirmed.

2. Antibiotic therapy. For dosages, see Chapter 148.

   1. Maternal infection. Most infants born to mothers with gonococcal infection do not experience infection; however, because there have been some reported cases, it is recommended that newborns receive a single injection of ceftriaxone. Although treatment failure after cephalosporin therapy is rare in the United States, minimum inhibitory concentrations to cephalosporins are increasing. Treatment failures have been reported more frequently from Asian countries. The mother and her sexual partner(s) should be evaluated (and treated) for other sexually transmitted infections, including HIV infection.

   2. Nondisseminated infection. Includes ophthalmia neonatorum; treatment is ceftriaxone given once. Alternative treatment for ophthalmia is cefotaxime as a single dose. Infants with ophthalmia should have their eyes irrigated with saline immediately and at frequent intervals until the discharge is eliminated. Topical antibiotics are inadequate and unnecessary with systemic therapy. Infants with conjunctivitis should be hospitalized and evaluated for disseminated infections (sepsis, arthritis, meningitis).

   3. Disseminated infection. For arthritis and septicemia: Ceftriaxone or cefotaxime for 7 days. For meningitis: Ceftriaxone or cefotaxime for 10–14 days. Use Cefotaxime if the infant has hyperbilirubinemia.

3. Isolation. All infants with gonococcal infection should be placed in contact isolation until effective parenteral antimicrobial therapy has been given for 24 hours. See Appendix F.

Excellent if treatment is started early.