Gonococcal Infections
The 5 Minute Pediatric Consult
Molly (Martha) W. Stevens
DEFINITION
Gonococcal infections include all diseases caused by Neisseria gonorrhoeae; an aerobic gram-negative diplococci, typically appearing as pairs with flattened adjacent sides.
PATHOPHYSIOLOGY
- Gonococcal infections are included in the category of sexually transmitted diseases (i.e., their major method of transmission in adolescents and adults is through sexual contact). In neonates, gonorrheal infections can also be acquired during passage through an infected birth canal.
- Incubation period is 2 to 7 days.
- Route of spread includes exposure to any infected mucous membrane or to infectious discharge.
ASSOCIATED DISEASES
- Pediatric gonococcal infections can be categorized by age group: the neonate, pre-pubertal children, and sexually active adolescents.
- Neonatal gonococcal diseases include gonococcal ophthalmia neonatorum, neonatal scalp abscess (complication after fetal scalp monitoring), and, rarely, vaginitis or systemic disease with bacteremia, arthritis, meningitis, or endocarditis.
- Gonococcal disease in the pre-pubertal age group usually occurs in the genital tract with vaginitis as the most common presenting manifestation. Pelvic inflammatory disease (PID), perihepatitis, and urethritis are rare. Anorectal and pharyngotonsillar involvement can also occur. As discussed in “Pitfalls,” child sexual abuse must be considered in all cases of gonococcal infection in prepubertal children outside the neonatal period and in any non-sexually active adolescent.
- Gonococcal disease in sexually active adolescents is similar to that in adults. In females, it is most frequently asymptomatic infection of the genital tract or symptomatic infection including endocervicitis, vaginitis, and urethritis, any of which can extend to cause PID, perihepatitis, or bartholinitis. In males, it most frequently occurs as symptomatic urethritis; extension can include epididymitis or proctitis. Asymptomatic or symptomatic infection of the urethra, rectum, pharynx, or conjunctivae can occur in both sexes. Hematogenous spread can cause arthritis-dermatitis syndrome, or rarely meningitis or endocarditis.
- Arthritis can occur at any age after bacteremia, most commnly in wrists, ankles, and knees, but any joint may be affected.
EPIDEMIOLOGY
- N. gonorrhoeae occurs only in human hosts. Approximately 1,000,000 new cases are reported each year in the United States.
- The highest incidence of infection is reported in males aged 20 to 24 years old and then in those 15 to 19 years old. The highest rates in females are from age 15 to 19 years.
COMPLICATIONS
- Gonoccal infection during pregnancy
- Both mother and infant at risk
- Gonococcal acute salpingitis or PID in first trimester has been associated with high incidence of fetal loss.
- Complications during labor and delivery include premature rupture of membranes, premature delivery, and chorioamnionitis.
- Salpingitis and PID
- Both salpingitis and PID can occur after the progression of untreated vaginal disease.
- Scarring that results from salpingitis has been estimated to cause sterility in up to 20% of women with a single infection and up to 50% of women after three episodes of infection.
- Partial obstruction of fallopian tube patency by scarring is a cause of ectopic pregnancy.
- There is an increased risk of progression of vaginal disease to salpingitis and PID in adolescents (approximately 15% of adolescents infected progress to PID).
- Disseminated disease
- Most common manifestation of disseminated gonococcal disease in children is gonococcal arthritis of the newborn; most cases involve multiple joints.
- Acute arthritis-dermatitis syndrome typically includes multiple joint tenosynovitis (with potential progression to arthritis) and papular/pustular lesions of the extremities.
- Gonococcal meningitis, endocarditis, myocarditis, and hepatitis are very rare in children.
- Ophthalmia neonatorum
- Gonococcal ophthalmia neonatorum can have a rapidly destructive course with corneal ulceration, scarring, and blindness if not treated early and aggressively.
PROGNOSIS
- Good prognosis is dependent on early diagnosis and effective irradication of infection prior to its progression and accompanying complications.
- Prognosis has been additionally improved by the recommendation to begin treatment of all forms of infection with an extended spectrum third-generation cephalosporin due to the increased prevalence of penicillin-resistant N. gonorrhoeae.
- Neonatal ophthalmia: other organisms that can cause neonatal conjunctivitis, including staphylococcal, streptococcal, and hemophilus species.
- Vaginitis in prepubertal child, other causes include: chemical or environmental irritants; pinworms; foreign body; infection by streptococci, trichomonas, diphtheroids, and other bacteria; and in cases of sexual abuse, chlamydia, or syphilis.
- Genitourinary tract infection in adolescents: other causes include chlamydia, syphilis, or trichomonas.
- Scalp infection: other causes include other bacteria/viruses, (see Pitfalls).
HISTORY
Question: Vaginal itching and crusting discharge?
Significance: Pre-pubertal gonorrhea vaginitis is typically a mild disease that rarely causes ascending or disseminated infection. Most children present with vaginal itching and a minor crusting discharge that may discolor underwear. Dysuria and white cells in the urine may also occur with gonorrhea vaginitis.
Question: Dysuria and discharge?
Significance: Urethritis presents with dysuria and a history of yellow-green mucopurulent discharge.
Question: Evidence of vaginal infection?
Significance: Post-pubescent vaginitis presents acutely with vulvar discomfort, dysuria, frequency, inflamed vulvar and vaginal mucosa, and a thick, yellow purulent discharge.
Question: Problem with walking or abdominal pain?
Significance: Ascending infection is characterized by difficulty walking, fever, emesis, and abdominal pain that is diffuse in the lower quadrants, or in perihepatitis, in the right upper quadrant with possible radiation to right scapula.
Finding: Neonatal ophthalmia
Significance: Usually presents 2 to 5 days after delivery as a bilateral discharge that is initially watery but quickly becomes mucopurulent with or without streaks of blood (incubation can be less than 3 days and up to 2 or 3 weeks postpartum). Conjunctivae are usually edematous with advanced disease showing edema or ulceration of the cornea. Lid edema is common.
Finding: Neonatal scalp abscess
Significance: Frequent complication of fetal scalp monitoring; determination of causative agent can be difficult.
Finding: Cervical motion tenderness
Significance: Characteristic on pelvic examination in patients with ascending cervical infection.
Finding: Purulent discharge
Significance: Common in both cervicitis and urethritis.
Test: Typical gram stain
Significance: Intracellular gram-negative diplococci. Confirmation is dependent of culture of N. gonorrhoeae.
Test: N. gonorrhoeae is cultured in a CO2-enriched atmosphere on chocolate agar or Thayer-Martin medium.
Significance: Culture and Gram stain are taken of the area of suspected infection by swabbing secretions (vagina, endocervix, male urethra, pharynx, rectum, conjunctivae) or by collecting the body fluid (such as cerebrospinal fluid, blood, or abscess or synovial).
Test: Cultures
Significance: In suspected sexual abuse, genital, rectal, and pharyngeal cultures should be collected prior to administration of antibiotics.
Test: STD panel
Significance: Test for other sexually transmitted diseases in the child in whom sexual abuse is suspected or when evaluating the sexually active adolescent. This includes testing for Chlamydia, syphilis, Trichomonas, and HIV.
Test: Non-culture methods for rapid identification are available.
Significance: Enzyme immunoassay, immunofluorescence, and DNA probes (they should not be used without culture in investigations of possible sexual abuse).
- Recommended therapy for all gonococcal infections in any age group is third-generation cephalosporin because of the increasing appearance of penicillin-resistant N. gonorrhoeae.
- Neonate: hospitalize after appropriate cultures (blood, cerebrospinal fluid, eye, or other site of infection) and initiation of treatment
- Non-disseminated dz: single dose of ceftriaxone, 25 to 50 mg/kg IV or IM (up to maximum dose of 125 mg); alternate for infant with hyperbilirubinemia is cefotaxime 100 mg/kg single dose.
- Disseminated dz: ceftriaxone 25 to 50 mg/kg IV or IM daily for 7 days, or cefotaxime 50 to 100 mg/kg/day IV or IM in two divided doses for 7 days; continue treatment for 10 to 14 days for meningitis.
- Neonates with gonococcal ophthalmia should have their eyes irrigated with sterile saline at presentation and at frequent intervals until the mucopurulent drainage has ceased.
- For patients outside the neonatal period, treatment and dosing charts from the 1997 Red Book.
INFECTION CONTROL
- Neonatal ophthalmia: Routine use of prophylactic ophthalmic ointment is mandatory in the United States. Instillation in both eyes of ointment occurs immediately after birth; choice of drugs includes 1% silver nitrate, 1% tetracycline, and 0.5% erythromycin ophthalmic ointments.
ISOLATION OF HOSPITALIZED PATIENT
Contact isolation precautions for all patients with gonococcal disease in the neonatal and pre-pubescent age groups is recommended; no special policies are recommended for other patients.
CONTROL MEASURES
- Infants of mothers with active gonococcal infections at birth should receive 25 to 50 mg/kg (maximum, 125 mg) ceftriaxone IM or IV for one dose only.
- Sexual contacts of persons with known gonorrhea should be examined, cultured, and treated as if they are infected with gonococcus.
- Any patient with a sexually transmitted disease should be evaluated for other common sexually transmitted diseases, including gonorrhea, Chlamydia, syphilis, and HIV. Consider hepatitis vaccination.
- Routine screening cultures of endocervix of all pregnant women at first prenatal visit; repeated at term if high risk.
- All cases of gonorrhea must be reported.
PITFALLS
- The diagnosis of suspected child sexual abuse must be considered in any child with a gonococcal infection outside the neonatal period. Cases of transmission via non-sexual contact have been reported (contact with freshly infected bedding, towels, toilet seat, or other fomite, or by digital transmission from an infected caregiver) but cannot be assumed without first ruling out sexual abuse. The source of infection should be determined in all cases, if possible.
- Scalp abscesses caused by gonorrhea are sometimes difficult to differentiate from staphylococcal species, Group B strep, H. influenzae, gram-negative enteric flora, or herpes simplex. For this reason, hospitalization of infants with scalp abscesses is recommended for appropriate differential work-up.
- Concurrent infection with other sexually transmitted diseases, including syphilis, Chlamydia, Trichomonas, and possibly HIV, should be considered and tested for; presumptive treatment for Chlamydia trachomatis is standard of care, as discussed, for gonococcal urethritis infections in children older than 9 years.
- Treatment of partners or source contact should be initiated in all cases.
- Careful differentiation by culture from other Neisseria species is necessary, especially in pre-pubertal children, due to the underlying question of child sexual abuse.
ICD-9-CM 098.0
American Academy of Pediatrics. Gonococcal infections. In: Peter G, ed. 1997 Red book: report of the Committee on Infectious Diseases, 24th ed. Elk Grove Village, IL: American Academy of Pediatrics, 1997:212–219.
American Academy of Pediatrics. Prevention of neonatal ophthalmia. In: Peter G, ed. 1997 Red book: report of the Committee on Infectious Diseases, 24th ed. Elk Grove Village, IL: American Academy of Pediatrics, 1997:601–603.
American Academy of Pediatrics. Pelvic inflammatory disease. In: Peter G, ed. 1997 Red book: report of the Committee on Infectious Diseases, 24th ed. Elk Grove Village, IL: American Academy of Pediatrics, 1997:390–394.
Feigin RD, Cherry JD, eds. Textbook of pediatric infectious diseases, 2nd ed. Philadelphia: WB Saunders, 1987:562–563, 566–568, 595–606.
Sung L. MacDonald NE. Gonorrhea: a pediatric perspective. Pediatr Rev 1998;19(1):13–16.
Copyright © 2000 Lippincott Williams & Wilkins
M. William Schwartz, Louis M. Bell, Jr., Peter M. Bingham, Esther K. Chung, David F. Friedman and Andrew E. Mulberg, The 5 Minute Pediatric Consult
