5.2.

2021 Gonococcal infection in the newborn - UpToDate

Official reprint from UpToDate®

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Gonococcal infection in the newborn

Author: Michael E Speer, MD
Section Editors: Leonard E Weisman, MD, Sheldon L Kaplan, MD
Deputy Editor: Carrie Armsby, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2021. | This topic last updated: Jun 19, 2019.

INTRODUCTION

Perinatal acquisition of sexually transmitted infections (STIs) 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: Evaluation, management, and prevention".)

● (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

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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 (STIs), 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 STIs.

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
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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 (STIs), 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

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(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 IV 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 STIs, 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 percent) ophthalmic ointment

• Tetracycline (1 percent) 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'.)

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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 to make certain that 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 [IV] or intramuscularly [IM]) or cefotaxime (if available; 100
mg/kg, administered IV or IM).

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 infants",
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].
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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 [IV] or intramuscularly) [1,2]. The duration of treatment is 7
days for septicemia, arthritis, or scalp abscess and 10 to 14 days for meningitis [1].
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 IV 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 ceftriaxone (25 to 50 mg/kg, up to a total dose of 125 mg, administered
intravenously [IV] or intramuscularly [IM]) or cefotaxime (if available; 100 mg/kg,
administered IV or IM) and should be evaluated for chlamydial infection [2]. (See "Chlamydia
trachomatis infections in the newborn", section on 'Diagnosis'.)

SUMMARY AND RECOMMENDATIONS

● Newborns acquire gonococcal infection during delivery. The perinatal transmission rate
is approximately 30 to 40 percent in women with cervical infection. (See 'Perinatal
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transmission' above.)

● 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 (STIs). (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 (IV) or intramuscularly (IM) at a dose of 25 to 50 mg/kg,
not to exceed 125 mg. Ceftriaxone should generally be avoided in infants with
clinically significant hyperbilirubinemia and neonates receiving calcium-containing
IV fluids. Alternative agents that can be used in these circumstances include
cefotaxime (if 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.)

● 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 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 IV or IM at a dose of 25 to 50
mg/kg per dose given once daily. The duration of treatment is 7 days for septicemia,

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arthritis, or scalp abscess and 10 to 14 days for meningitis. Ceftriaxone should

generally be avoided in infants with clinically significant hyperbilirubinemia and
neonates receiving calcium-containing IV fluids. Alternative agents that can be used
in these circumstances include cefotaxime (if available) or ceftazidime. (See 'Other
localized infection' above and 'Disseminated infection and scalp abscess' above.)

● 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.)

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REFERENCES
1. American Academy of Pediatrics. Gonococcal infections. In: Red Book: 2018 Report of th
e Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Lon
g SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.355.

2. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually
transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.

3. Centers for Disease Control and Prevention (CDC) 2016 sexually transmitted diseases su
rveillance: STDs in women and infants. Available at: https://www.cdc.gov/std/stats16/wo
menandinf.htm (Accessed on October 10, 2017).

4. Desenclos JC, Garrity D, Scaggs M, Wroten JE. Gonococcal infection of the newborn in
Florida, 1984-1989. Sex Transm Dis 1992; 19:105.

5. Alexander ER. Gonorrhea in the newborn. Ann N Y Acad Sci 1988; 549:180.

6. Elliott B, Brunham RC, Laga M, et al. Maternal gonococcal infection as a preventable risk
factor for low birth weight. J Infect Dis 1990; 161:531.

7. Amstey MS, Steadman KT. Asymptomatic gonorrhea and pregnancy. J Am Vener Dis
Assoc 1976; 3:14.

8. Israel KS, Rissing KB, Brooks GF. Neonatal and childhood gonococcal infections. Clin
Obstet Gynecol 1975; 18:143.

9. Donders GG, Desmyter J, De Wet DH, Van Assche FA. The association of gonorrhoea and
syphilis with premature birth and low birthweight. Genitourin Med 1993; 69:98.

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10. Edwards LE, Barrada MI, Hamann AA, Hakanson EY. Gonorrhea in pregnancy. Am J
Obstet Gynecol 1978; 132:637.

11. Charles AG, Cohen S, Kass MB, Richman R. Asymptomatic gonorrhea in prenatal
patients. Am J Obstet Gynecol 1970; 108:595.

12. Handsfield HH, Hodson WA, Holmes KK. Neonatal gonococcal infection. I. Orogastric
contamination with Neisseria gonorrhoea. JAMA 1973; 225:697.

13. Di Bartolomeo S, Mirta DH, Janer M, et al. Incidence of Chlamydia trachomatis and
other potential pathogens in neonatal conjunctivitis. Int J Infect Dis 2001; 5:139.

14. Nsanze H, Dawodu A, Usmani A, et al. Ophthalmia neonatorum in the United Arab
Emirates. Ann Trop Paediatr 1996; 16:27.

15. Pandey KK, Bhat BV, Kanungo R, et al. Clinico-bacteriological study of neonatal
conjunctivitis. Indian J Pediatr 1990; 57:527.

16. Bradley JS, Wassel RT, Lee L, Nambiar S. Intravenous ceftriaxone and calcium in the
neonate: assessing the risk for cardiopulmonary adverse events. Pediatrics 2009;
123:e609.

17. Alternatives to consider during cefotaxime shortage. AAP News. Available at: http://ww
w.aappublications.org/content/early/2015/02/25/aapnews.20150225-1 (Accessed on Ma
y 22, 2017).

18. Laga M, Meheus A, Piot P. Epidemiology and control of gonococcal ophthalmia

neonatorum. Bull World Health Organ 1989; 67:471.

19. Guirguis-Blake JM, Evans CV, Rushkin M. Ocular Prophylaxis for Gonococcal Ophthalmia
Neonatorum: Updated Evidence Report and Systematic Review for the US Preventive
Services Task Force. JAMA 2019; 321:404.

20. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular Prophylaxis for
Gonococcal Ophthalmia Neonatorum: US Preventive Services Task Force Reaffirmation
Recommendation Statement. JAMA 2019; 321:394.

21. Darville T. Gonorrhea. Pediatr Rev 1999; 20:125.

22. Varady E, Nsanze H, Slattery T. Gonococcal scalp abscess in a neonate delivered by

caesarean section. Sex Transm Infect 1998; 74:451.

23. Cooperman MB. Gonococcus arthritis in infancy: a clinical study of 44 cases. Am J Dis
Child 1927; 33:932.

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24. Kohen DP. Neonatal gonococcal arthritis: three cases and review of the literature.
Pediatrics 1974; 53:436.

25. Babl FE, Ram S, Barnett ED, et al. Neonatal gonococcal arthritis after negative prenatal
screening and despite conjunctival prophylaxis. Pediatr Infect Dis J 2000; 19:346.

26. Erdem G, Schleiss MR. Gonococcal bacteremia in a neonate. Clin Pediatr (Phila) 2000;
39:43.

27. Asnis DS, Brennessel DJ. Gonococcal scalp abscess: a risk of intrauterine monitoring.
Clin Pediatr (Phila) 1992; 31:316.

Topic 4983 Version 26.0

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GRAPHICS

Gonococcal ophthalmia neonatorum

Reproduced from: The Public Health Image Library, Centers for Disease Control and Prevention. Photo by Dr. J
Pledger.

Graphic 66751 Version 1.0

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Clinical findings in neonatal sepsis

Finding Frequency*

Hyperthermia +++

Respiratory distress +++

Tachycardia +++

Lethargy ++

Poor feeding ++

Apnea ++

Bradycardia ++

Poor perfusion/hypotension ++

Vomiting ++

Jaundice ++

Hepatomegaly ++

Cyanosis +

Hypothermia +

Irritability +

Seizures +

Abdominal distension +

Diarrhea +

* +++: commonly associated (≥50 percent of cases); ++: frequently associated (25 to 50 percent); +: occasionally associated (<25
percent).

References:
1. Nizet V, Klein JO. Bacterial sepsis and meningitis. In: Infectious Diseases of the Fetus and Newborn Infant, 7 th ed, Remington JS, Klein
JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2010. p.244.
2. Stoll BJ, Hansen NI, Sánchez PJ, et al. Early onset neonatal sepsis: The burden of group B Streptococcal and E. coli disease continues.
Pediatrics 2011; 127:817.

Graphic 72985 Version 6.0

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Contributor Disclosures
Michael E Speer, MD Nothing to disclose Leonard E Weisman, MD Grant/Research/Clinical Trial
Support: Vax-Immune [Ureaplasma diagnosis, vaccines, antibodies, other medical diagnostics and pre-
analytical devices]. Patent Holder: Baylor College of Medicine [Ureaplasma diagnosis, vaccines,
antibodies, process for preparing biological samples]. Equity Ownership/Stock Options: Vax-Immune
[Ureaplasma diagnosis, vaccines, antibodies, other medical diagnostics and pre-analytical
devices]. Sheldon L Kaplan, MD Grant/Research/Clinical Trial Support: Pfizer [Streptococcus
pneumoniae]; Merck [Staphylococcus aureus]; MeMed Diagnostics [Bacterial and viral infections];
Allergan [Staphylococcus aureus]. Other Financial Interest: Pfizer [PCV13; linezolid]; Elsevier [Pediatric
infectious diseases]. Carrie Armsby, MD, MPH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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