Neisseria Gonorrhea
Similar to infection with C. trachomatis, infection from N. gonorrhea among neonates results from perinatal exposure to the mother’s infected cervix. Acute illness typically is seen between 2 and 5 days after birth and had been described clinically as “sudden, severe, grossly purulent conjunctivitis.” The prevalence of infection among infants depends on the prevalence of infection among pregnant women, whether pregnant women are screen and treated for gonorrhea, and whether newborns receive ophthalmia prophylaxis. The most severe manifestations of N. gonorrhea infection in newborns are conjunctivitis and sepsis. Gonococcal sepsis in the neonate may also include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and infection at sites of fetal monitoring.
Without adequate prophylaxis, an estimated 20 to 42% of infants vaginally born to infected mothers will develop gonococcal conjunctivitis. In Belgium, the overall prevalence of gonococcal conjunctivitis is very low (0.04 cases per 1000 live births) compared to the United Stated (0.3 cases per 1000 live births). N. gonorrhea causes neonatal conjunctivitis relatively infrequently in the United States but identifying and treating this infection is important as it can result in perforation of the globe and blindness.
Gram stain showing white blood cells in the eye exudate should alert the provider to suspect infection from N. gonorrhea, but non-gonococcal causes of neonatal conjunctivitis include Moraxella catarrhalis and other Neisseria species, which are indistinguishable from N. gonorrhea, on grams stain, thus culture on proper media to select N. gonorrhea in mandatory and diagnosis cannot be made solely from grain stain results.
The gold standard for recovery of N. gonorrhea from an ocular specimen is culture. Currently the FDA approves NAA tests on endocervical swabs from women, urethral swabs from men, and urine from both men and women. Previous studies on neonates suspected of neonatal conjunctivitis due to N. gonorrhea have shown that PCR is equal or superior to culture from ocular specimens, however, these tests do not have FDA approval; therefore Children’s Mercy laboratory utilizes culture to identify N. gonorrhea. There are no new recommendations for recovery of N. gonorrhea other than culture and NAA/PCR tests are still not approved for eye surface use. Based on current literature the Care Process Model team recommends the use of culture for detection of N. gonorrhea in the neonate with suspected conjunctivitis.
Rationale, current evidence, and consensus statement
Neonates with suspected gonococcal conjunctivitis should be evaluated for signs of disseminated infection (such as sepsis, arthritis, and meningitis) and scalp abscess. Based on consensus from the 2015 RedBook and 2015 CDC STD treatment guidelines, and in conjunction with Children’s Mercy expert consensus from the Department of Infectious Disease, those neonates perceived at high risk or high clinical suspicion from neonatal conjunctivitis from N. gonorrhea, recommended to obtain cultures of blood, CSF, and other potential sites of infection and recommended that these neonates be admitted to the hospital and should be managed in consultation with infectious-disease and ophthalmology.
References:
Committee on Infectious Diseases. (2015). Red Book: Report of the Committee on Infectious Diseases (2015)(Kimberlin DW, Brady, MT, Jackson MA, & Long, SS Eds. 30 ed.).
Hammerschlag, M.R., Robilin, P.M., Gelling, M., Tsumura, N., Jule, J.E., & Kulten, A. (1997). Use of polymerase chain reaction for the detection of Chlamydia trachomatis in ocular and nasopharyngeal specimens from infants with conjunctivitis. Pediatric Infect Dis J, 16(3), 293-297
Johnson, R.E., Newhall, W.J., Papp, J.R., Knaoo, J.S., Black, C.M., Gift, T.L., . . . Berman, S.M. (2002). Screening tests to detect Chlamydia trachmotis and Neisseria gonorrhea infections—2002. MMWR Recomm Rep, 51(RR-15), 1-38; quiz CE31-34
Laga, M., Mähers, A., & Pilot, P. (1989). Epidemiology and control of gonococcal ophthalmia neonatorum. Bull World Health Organ, 67(5), 471-477.
MacDonald, N., Mailman, T., & Desai, S. (2008). Gonococcal infections in newborns and in adolescents. Adv Exp med Biol, 609, 108-130. doin: 10.1007/978-0-387-73960-1_9
Talley, A.R., Garcia-Ferrer, F., Laycock, K.A., Essary, L.R., Holcomb, W.L., Jr., Flowers, B. E., . . .Pepose, j.S. (1994). Comparative diagnosis of neonatal chlamydial conjunctivitis by polymerase chain reaction and mcCoy cell culture. Am J Ophthalmol, 117(1), 50-57.
Workowski, K.A., Bolan, G.A., Centers for Disease, C., & Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 64(RR-03), 1-137.
Zuppa, A.A., D’Andrea, V., Catenazzi, P., Scorrano, A., & Romagnoli, C. (2011). Ophthalmia neonatorum: what kind of prophylaxis? J Matern Fetal Neonatal Med, 24 (6), 769-773. doin:10.3109/14767058.2010.531326
These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.