Gonococcal Conjunctivitis

John Costumbrado; Sassan Ghassemzadeh.

Author Information

Last Update: February 15, 2019.

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Introduction
While typically thought of as a disease in neonates, gonococcal conjunctivitis
(GC) is an infectious process that has also become an increasing issue in
other age groups. When it occurs in neonates, GC is also known as
gonococcal ophthalmia neonatorum and is most likely due to maternal
transmission during birth. In older age groups, GC is more associated with
sexually transmitted infections (STIs) but can also present without evidence
of concomitant genital infection. The condition is important to recognize as
untreated cases can lead to significant life-threatening like meningitis and/or
altering consequences for patients, for example, blindness.[1][2][3][4]
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Etiology
GC is due to ophthalmic infection with Neisseria gonorrhoeae, which is a
gram-negative diplococcus. In neonates, transmission of N. gonorrhoeae and
subsequent development of GC often occurs during delivery and exposure to
infectious vaginal secretions. This occurs since the mucosa of the cervix and
urethra of infected mothers can act as bacterial reservoirs. Even with delivery
via cesarean section, vertical transmission of N. gonorrhoeae is still possible.
Approximately 10% of neonates exposed to gonorrheal exudates during
delivery may go on to develop GC, even with appropriate prophylaxis. In
populations other than neonates, transmission can occur via direct sexual
contact with infective secretions or indirectly, for example via manual or
fomite transmission, though this is thought to be less likely since N.
gonorrhea does not typically survive more than a few minutes outside the
human body. There has also been evidence that suggests that GC could
potentially be due to different strains of gonococci that are not associated
with STIs.[5][6][7]
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Epidemiology
Worldwide, the incidence of gonococcal infection in the newborn is less than
1%. Developed countries tend to have lower incidences due to the availability
of screening and treatment options. Rates in developing countries are likely
to be significantly higher considering the prevalence of gonococcal infection
in pregnancy nears 5% in some parts of Africa. In the United States, the
incidence of conjunctivitis ranges from 1% to 2% in neonates with the
incidence of neonatal GC estimated to be less than 1%. As mentioned
previously, in neonates that have appropriate chemoprophylaxis, up to 10%
may still develop GC compared to up to 48% of neonates that do not.
In the non-neonatal populations, GC is rare. In the United States, STI
surveillance estimates nearly 146 cases of gonorrhea per 100,000 population,
but specific estimates of GC have not been well-studied. However, a recent
study in Ireland estimated that the prevalence of GC was 0.19 cases per 1000
patients evaluated for eye emergencies with the majority presenting in young
adult males.
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Pathophysiology
The main concept is that N. gonorrhoeae can attach to and penetrate the
epithelial cells of mucosal surfaces such as the conjunctiva. Once inside, the
bacteria can proliferate and induce pro-inflammatory mechanisms. However,
there is evidence that N. gonorrhoeae have developed methods for evading
and even modulating immune responses, which can potentially lead to
disseminated infection, for example, bacteremia or meningitis.
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History and Physical

Neonatal GC is often acquired during delivery; thus, there usually is a history
of suspected or confirmed maternal gonorrheal infection. Bacterial
conjunctivitis can occur at any time, but GC is considered in symptomatic
neonates after the first day of life, specifically, days 2 to 5, since chemical
conjunctivitis (secondary to silver nitrate, antibiotic drops) is often the cause
in the first 24 hours. A physical exam may reveal the following:
 Conjunctival injection, chemosis
 Edema of the eyelids
 Mucopurulent discharge
 Tenderness of the globe
 Lymphadenopathy, preauricular
In the non-neonatal population, GC may present with similar symptoms and
should at least be considered in sexually active individuals that present with
conjunctivitis with or without genital symptoms. Regardless, a detailed
sexual history of the mother and non-neonatal cases of conjunctivitis should
be obtained to refine the differential diagnoses for conjunctivitis.
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Evaluation
For patients presenting with conjunctivitis concerning for possible GC,
further diagnostics are suggested to confirm the diagnosis. A sampling of
conjunctival scrapings or exudative fluid can be sent for the following:
 Gram stain, which may reveal gram-negative intracellular diplococci
 Culture on Thayer-Martin media and/or chocolate agar for N.
gonorrhoeae and blood agar for non-gonococcal species
 Polymerase chain reaction (PCR) can also be used to test for N.
gonorrhoeae as well as Chlamydia trachomatis
 Screening for other STIs such as the human immunodeficiency virus
(HIV) is also recommended in mothers and non-neonatal cases due to
co-infections that can occur with STIs
 Consideration should also be given to taking genital and throat swabs in
patients with risk factors.
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Treatment / Management
Due to the progression risk of disseminated gonococcal infection, neonates
with GC should be approached as emergent cases that warrant admission and
observation. The most effective treatment of GC is prevention, and it is
recommended that females be screened for gonorrhea and other STIs if
considered high-risk (prior history of STI, commercial sex workers) and
should be appropriately treated. Nevertheless, cases of neonatal GC can occur
even with appropriate prophylactic measures. Below is a summary of the
recommended therapies.[8][9][10][11]
Neonatal Prophylaxis
 Erythromycin (0.5%) ophthalmic ointment, or
 Tetracycline (1%) ophthalmic ointment
Symptomatic or High-Risk (mother with untreated gonorrhea) neonate
 Ceftriaxone (25 mg/k to 50 mg/kg, max 125 mg intravenously (IV) or 
intramuscularly (IM), single dose, or
 Cefotaxime (100 mg/kg IV/IM), single dose, which may be preferred if
available due to the risk of increasing bilirubin levels associated with
ceftriaxone
 Hourly saline lavage
Non-Neonate with Symptoms (generally, can be managed on an outpatient
basis)
 Ceftriaxone (1 gm IM), single dose, and
 Azithromycin (1 gm oral), single dose, which is added on due to the
frequent co-infection with Chlamydia trachomatis
 Saline lavage can be considered but is not a necessity
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Pearls and Other Issues

GC is a disease process that should not be dismissed. Untreated cases can
result in severe complications such as vision loss if the bacteria penetrate
further and cause corneal ulceration and scarring. Timely ophthalmology
consultation is warranted due to the significant risks to the patient’s vision.
Providers should also be aware of the risks of a systemic infection that may
present as septic arthritis, meningitis, or septicemia. Furthermore, attention
should be given to appropriate treatment since fluoroquinolone resistance has
become a growing issue, which is part of the reason why cephalosporins have
become the mainstay of gonococcal treatment.
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Enhancing Healthcare Team Outcomes

Gonococcal conjunctivitis is a serious illness that is best managed by a
multidisciplinary team that consists of a pediatrician, ophthalmologist,
infectious disease expert, nurse practitioner and the primary care physician.
Untreated cases can result in severe complications such as vision loss if the
bacteria penetrate further and cause corneal ulceration and scarring. Timely
ophthalmology consultation is warranted due to the significant risks to the
patient’s vision. Providers should also be aware of the risks of a systemic
infection that may present as septic arthritis, meningitis, or septicemia.
Furthermore, attention should be given to appropriate treatment since
fluoroquinolone resistance has become a growing issue, which is part of the
reason why cephalosporins have become the mainstay of gonococcal
treatment.Following treatment, the outcomes in most infants are good.
[12] (Level V)
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Questions
To access free multiple choice questions on this topic, click here.
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References
1.
 Lessing JN, Slingsby TJ, Betz M. Hyperacute Gonococcal
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Fiorito TM, Noor A, Silletti R, Krilov LR. Neonatal Conjunctivitis
Caused by Neisseria cinerea: A Case of Mistaken Identity. J Pediatric
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 Hammerschlag MR, Smith-Norowitz T, Kohlhoff SA. Keeping an Eye
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