Basics
Description
Neisseria gonorrhoeae, an aerobic gram-negative diplococcus, is the etiologic agent of gonorrhea.
Epidemiology
- Gonorrhea is the second most common sexually transmitted infection (STI) in the United States.
- Coinfection with Chlamydia trachomatis commonly occurs in sexually active patients.
Incidence
- In the United States, there are >800,000 new cases of gonorrhea each year. Rates of infection are highest among adolescents and young adults.
- Racial disparities are present, with a disproportionately high incidence in ethnic minorities.
Prevalence
- Less than half of all infections are estimated to be detected or reported.
Risk Factors
- Vaginal delivery to an infected mother is a risk factor for neonatal disease.
- Sexual abuse should be considered in all prepubertal children presenting with gonorrhea.
- Risk factors for sexually active adolescents include multiple sexual partners, lack of condom use, and inconsistent screening by health care providers.
- The risk of male-to-female transmission is 50% per episode of vaginal intercourse; the risk of female-to-male transmission is ~20% per episode. Rectal intercourse is also a mode of transmission.
General Prevention
- Ophthalmia neonatorum: Prophylactic ophthalmic ointment is mandatory in the United States regardless of method of delivery. Instillation of 0.5% erythromycin ophthalmic ointment in both eyes occurs immediately after birth.
- Maternal infection: Routine screening cervical cultures should be performed at the 1st prenatal visit; repeat at term if high risk.
Pathophysiology
- Incubation period is 2-7 days.
- Transmission results from contact with infected mucosa and secretions, usually through vaginal delivery, sexual activity, and (rarely) household contact in prepubertal children.
- In prepubertal children, genital infection is mild; ascending or disseminated infection rarely occurs. In adolescents, estrogenization protects the vagina from infection and instead serves as a conduit for cervical exudate.
- Immunity is not induced by infection.
Commonly Associated Conditions
Pediatric gonococcal infections can be categorized by age group: neonates, prepubertal children, and sexually active adolescents.
- Neonatal gonococcal diseases include ophthalmia neonatorum, scalp abscess (complication of fetal scalp monitoring), and, rarely, disseminated disease.
- Prepubertal gonococcal disease usually occurs in the genital tract. Vaginitis is the most common manifestation. Pelvic inflammatory disease (PID), perihepatitis (Fitz-Hugh-Curtis syndrome), urethritis, proctitis, and pharyngitis rarely occur. Consider sexual abuse.
- Gonococcal diseases in sexually active adolescents resemble those found in adults and may be asymptomatic.
- Both sexes: pharyngitis, anorectal infection, tenosynovitis-dermatitis syndrome, or arthritis
- Females: Genital tract infection may cause urethritis, vaginitis, and endocervicitis. Ascending genital tract infection may lead to PID and perihepatitis.
- Males: Acute urethritis is the predominant manifestation. Epididymitis also occurs.
Diagnosis
History
- In neonates, assess for risk factors such as premature or prolonged membrane rupture, presence of fetal scalp monitoring, and maternal history of infection.
- Onset of eye findings in ophthalmia neonatorum is usually between 2 and 5 days of age but ranges from 1 day to several weeks.
- Sexual history should be thoroughly reviewed with all adolescents.
- Vaginal itching and discharge may indicate vaginitis.
- Urethritis: purulent urethral discharge and dysuria without urgency or frequency
- Abdominal pain
- Ascending infection is characterized by diffuse lower quadrant abdominal pain, including discomfort with ambulation. Low back pain, dyspareunia, and abnormal vaginal bleeding occasionally occur. Fever, chills, nausea, and vomiting may be present. Acute perihepatitis causes right upper quadrant pain and results from direct extension of infection from the fallopian tube to the liver capsule.
- Symptoms of extragenitourinary disease including sore throat, joint pain, or rash
Physical Exam
- Ophthalmia neonatorum
- Bilateral eyelid edema, chemosis, and copious purulent discharge
- Neonatal scalp abscess
- PID
- Signs include cervical motion tenderness, pelvic adnexal tenderness (usually bilateral), and lower or right upper quadrant abdominal pain (with perihepatitis). Many females with PID also have mucopurulent cervical discharge.
- Cervicitis or urethritis: purulent vaginal or penile discharge
- Rash: classically discrete, tender, necrotic pustules on distal extremities, although macules, papules, and bullae occasionally occur
- Joint findings: tenosynovitis, migratory arthritis
Diagnostic Tests & Interpretation
Lab
Initial Lab Tests
- Gram stain (low sensitivity) and culture of infected exudate or body fluid
- Intracellular gram-negative diplococci on gram stain. Confirmation depends on isolation of N. gonorrhoeae from culture. Specimens are immediately inoculated onto Thayer-Martin or chocolate-blood agar-based media at room temperature and incubated in an enriched CO2 environment. In cases of suspected sexual abuse, collect genital, rectal, and pharyngeal cultures.
- Nonculture gonococcal tests
- Nucleic acid amplification tests (NAATs) for urine specimens (freshly voided specimens), male urethral, female endocervical or vaginal (self-administered introital) swabs are highly sensitive and specific but should not be used in investigations of possible sexual abuse (possibility of false-positive results). NAATs also cannot provide antimicrobial susceptibility test results.
- STI panel
- Test for other STIs including C. trachomatis, Treponema pallidum (syphilis), Trichomonas vaginalis, and HIV in children in whom sexual abuse is suspected or when evaluating sexually active adolescents.
- CBC, ESR, C-reactive protein, and blood culture may be obtained to evaluate for inflammation and disseminated disease.
- Synovial fluid cell count and culture in patients with joint swelling (cell count often >50,000 WBC/μL with differential of >90% PMNs)
- Synovial fluid cultures are positive in 50% with gonococcal arthritis; blood cultures are positive in less than 1/3, although cultures from other sites (e.g., cervix, urethra) are frequently positive.
Imaging
Pelvic ultrasound may detect ectopic pregnancy and, in PID, may reveal thick, dilated fallopian tubes or tuboovarian abscess.
Differential Diagnosis
- Ophthalmia neonatorum: Other causes of neonatal conjunctivitis include infection with C. trachomatis, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus species, chemical conjunctivitis, and herpes simplex virus (HSV).
- Scalp infection: Gonococcal scalp abscesses may be difficult to distinguish from abscesses caused by staphylococcal species, group B Streptococcus, H. influenzae, Enterobacteriaceae, and HSV.
- Vaginitis: In the prepubertal child, other causes include chemical or environmental irritants, pinworms, foreign body, and infections (i.e., streptococci, T. vaginalis). In cases of sexual abuse, C. trachomatis and syphilis may occur.
- Genitourinary tract infection: In adolescents, other causes include C. trachomatis, syphilis, and T. vaginalis.
- Arthritis: other bacterial causes of septic arthritis, Reiter syndrome, and reactive arthritis
- Abdominal pain: ectopic pregnancy, appendicitis, cholecystitis, UTI/pyelonephritis, and ovarian torsion
Treatment
Medication
First Line
- Changing resistance patterns in the United States led to extended-spectrum cephalosporin as initial therapy.
- Neonates
- Ophthalmia neonatorum: ceftriaxone 25-50 mg/kg IV or IM (single dose; maximum, 125 mg); alternate agent for infants with hyperbilirubinemia is cefotaxime 100 mg/kg IV or IM (single dose).
- Neonates with gonococcal ophthalmia also require eye irrigation with sterile saline at presentation and at frequent intervals until mucopurulent drainage has ceased.
- Disseminated infection: cefotaxime for 7 days for bacteremia, 10-14 days for meningitis
- Older children and adolescents
- Uncomplicated gonococcal infection (including cervicitis, epididymitis, or pharyngeal infection): Cefixime is no longer recommended as 1st-line treatment. Give a single IM dose of ceftriaxone 250 mg. Follow with a treatment regimen for C. trachomatis.
- If ceftriaxone is not available, give single-dose cefixime 400 mg orally, along with C. trachomatis treatment. In cases of severe cephalosporin allergy, give single dose azithromycin 2 g. Alternative regimens to ceftriaxone require tests of cure in 1 week.
- PID: See Pediatric Red Book or 2010 CDC guidelines for treatment regimens.
- Complicated gonococcal infection: ceftriaxone or cefotaxime for 7 days (arthritis and septicemia), 10-14 days (meningitis), or ≥28 days (endocarditis). Include concomitant C. trachomatis therapy.
- Pursue empiric treatment of sexual partners.
Inpatient Considerations
Admission Criteria
- Neonates: Hospitalize and obtain appropriate cultures (conjunctivae, blood, CSF, or those from any other site of infection).
- Prepubertal children: safety concerns present or complicated disease
- Sexually active adolescents: PID with inability to tolerate oral antibiotics, complicated disease requiring further monitoring
Ongoing Care
Follow-up Recommendations
- Provide risk reduction education.
- Sexual contacts (including mother and her partner[s]) of patients with gonorrhea should be counseled and treated.
- Evaluate for concurrent infection with other sexually transmitted diseases, including syphilis, C. trachomatis, T. vaginalis, hepatitis B, and HIV. Patients whose age has progressed beyond the neonatal period should be treated presumptively for C. trachomatis infection.
- All cases of gonorrhea must be reported to public health officials.
- Contact isolation precautions are recommended for all hospitalized patients with gonococcal disease in the neonatal and prepubertal age groups; no special policies are recommended for other patients.
- Evaluate prepubertal children for abuse.
Alert
Pitfalls
- Failure to consider the diagnosis of sexual abuse in a prepubertal child with a gonococcal infection. Cases of transmission via nonsexual contact have been reported (i.e., from freshly infected towels/fomites, childhood sexual play, or by digital transmission from an infected caregiver), but such mode cannot be assumed without first excluding sexual abuse.
- Failure to use culture to diagnose infection in cases of suspected abuse
- Failure to differentiate N. gonorrhoeae by culture from other Neisseria species, especially in prepubertal children, given concern for sexual abuse
- Failure to consider acute gonococcal perihepatitis/Fitz-Hugh-Curtis syndrome in females with right upper quadrant pain
Prognosis
Prognosis has been improved by treating all forms of infection with a 3rd-generation cephalosporin.
Complications
- Gonococcal infection during pregnancy is associated with spontaneous abortion, preterm labor, and perinatal infant mortality.
- Ophthalmia neonatorum may rapidly progress to corneal ulceration and perforation, with subsequent scarring and blindness.
- PID
- Endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis occur as a consequence of untreated vaginal disease.
- Scarring secondary to salpingitis causes sterility in ≤20% of women with a single infection and ≤50% of women after 3 episodes of infection.
- Risk of ectopic pregnancy increases 7-fold after 1 episode of PID.
- In males, rare complications include periurethral abscess, acute prostatitis, seminal vesiculitis, and urethral strictures.
- Disseminated disease
- Consider evaluation for complement deficiency in those with multiple episodes.
- In neonates, arthritis is the most frequent systemic manifestation; symptoms develop 1-4 weeks after delivery. Involvement of multiple joints is typical, and most infants do not have ophthalmia neonatorum.
- In older children and adolescents, septic arthritis (1 joint) and a characteristic poly-arthritis-dermatitis syndrome are possible manifestations.
- Gonococcal meningitis, endocarditis, and osteomyelitis are rare in children.
- Gonococcal infection can serve as a cofactor in increasing HIV infection and transmission.
Additional Reading
- American Academy of Pediatrics. Gonococcal infections. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:336-344.
- Centers for Disease Control and Prevention. Update to CDC's sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594. [View Abstract]
- Comkornruecha M. Gonococcal infections. Pediatr Rev. 2013;34(5):228-234. [View Abstract]
- Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506-512. [View Abstract]
Codes
ICD09
- 098.0 Gonococcal infection (acute) of lower genitourinary tract
- 760.2 Maternal infections affecting fetus or newborn
- 098.40 Gonococcal conjunctivitis (neonatorum)
- 098.89 Gonococcal infection of other specified sites
- 098.7 Gonococcal infection of anus and rectum
- 771.89 Other infections specific to the perinatal period
- 098.15 Gonococcal cervicitis (acute)
- 098.49 Other gonococcal infection of eye
- 098.0 Gonococcal infection (acute) of lower genitourinary tract
ICD10
- A54.9 Gonococcal infection, unspecified
- P39.8 Other specified infections specific to the perinatal period
- P39.1 Neonatal conjunctivitis and dacryocystitis
- A54.89 Other gonococcal infections
- A54.39 Other gonococcal eye infection
SNOMED
- 15628003 Gonorrhea (disorder)
- 240571007 Neonatal gonococcal infection (disorder)
- 28438004 gonococcal conjunctivitis neonatorum (disorder)
- 237096004 Neonatal gonococcal vulvovaginitis (disorder)
- 240581006 gonococcal female pelvic infection (disorder)
- 237095000 Gonococcal vulvovaginitis
- 237083000 Gonococcal cervicitis (disorder)
FAQ
- Q: What are the advantages of the NAATs for making a diagnosis?
- A: The transcription-mediated amplification (TMA) test of urine samples, approved by the FDA for women, can be used to simultaneously test for C. trachomatis and N. gonorrhoeae.
- Q: When is this test not approved?
- A: For rectal and pharyngeal swabs and for cases of suspected abuse