Gonococcal Infections
Gonococcal Infections: Excerpt from The 5-Minute Pediatric Consult
Samir S. Shah, MD, MSCE
Gonococcal Infections - BASICS
Gonococcal Infections - description
Neisseria gonorrhoeae, an aerobic Gram-negative diplococcus, is the etiologic agent of gonorrhea.
Gonococcal Infections - general prevention
- Neonatal ophthalmia: Routine use of prophylactic ophthalmic ointment is mandatory in the US. Instillation of ointment in both eyes occurs immediately after birth; choice of drugs includes 1% silver nitrate, 1% tetracycline, and 0.5% erythromycin ophthalmic ointments.
- Routine screening cervical cultures should be performed at the 1st prenatal visit; repeat at term if high risk.
Gonococcal Infections - epidemiology
- Gonorrhea is the most common STD found in sexually abused children.
- Gonococcal conjunctivitis, although rare in adults, occurs by autoinoculation of infected secretions in patients with anogenital infection.
Gonococcal Infections - prevalence
- In the US, >1 million new infections are diagnosed each year. The highest rates of occurrence are found in 15–24-year-old women and men.
- Pelvic inflammatory disease occurs in 10–20% of women with endocervical gonococcal infection.
- 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, but orogenital contact is not.
Gonococcal Infections - pathophysiology
- Incubation period is 2–5 days.
- Transmission results from contact with infected mucous membranes and secretions, usually through sexual activity, parturition, and (very rarely) household contact in prepubertal children.
- Immunity is not induced by infection.
Gonococcal Infections - etiology
N. gonorrhoeae
Gonococcal Infections - 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, vaginitis or systemic disease with arthritis, bacteremia, funisitis, or meningitis.
- Prepubertal gonococcal disease usually occurs in the genital tract. Vaginitis is the most common manifestation. Pelvic inflammatory disease, perihepatitis, urethritis, proctitis, and pharyngitis rarely occur. Sexual abuse must be considered when genital, rectal, or pharyngeal gonococcal infections occur in prepubertal children.
- Sexually active adolescents have a spectrum of gonococcal disease similar to findings in adults:
- Both sexes: Pharyngitis or anorectal infection (with or without symptoms)
- Females: Genital tract infection may be asymptomatic or cause urethritis, vaginitis, and endocervicitis. Ascending genital tract infection may lead to pelvic inflammatory disease and perihepatitis
- Males: Acute urethritis is the predominant manifestation. Epididymitis occurs infrequently.
Gonococcal Infections - DIAGNOSIS
Gonococcal Infections - signs & symptoms
Gonococcal Infections - history
- Premature or prolonged membrane rupture is a risk factor for conjunctivitis. Fetal scalp monitoring places the infant at risk for gonococcal scalp abscess.
- Vaginal itching and discharge are signs and symptoms of vaginitis. Prepubertal gonorrheal vaginitis is typically a mild disease that rarely causes ascending or disseminated infection. In adolescents, estrogenization protects the vagina from infection. Instead, the vagina serves as a conduit for cervical exudate.
- Urethritis: Purulent urethral discharge and dysuria without urgency or frequency
- Abdominal pain:
- Ascending infection is characterized by diffuse lower quadrant abdominal pain, which may cause significant discomfort with ambulation. Low back pain, dyspareunia, and abnormal vaginal bleeding occasionally occur. Fever, chills, nausea, and vomiting may be present. Acute perihepatitis (Fitz-Hugh-Curtis syndrome) causes right upper quadrant pain and results from direct extension of infection from the fallopian tube to the liver capsule.
- Symptoms of pharyngitis, arthritis, dermatitis, meningitis, or endocarditis:
- Gonococcal infections may occur outside the genitourinary tract.
Gonococcal Infections - physical exam
- Neonatal ophthalmia:
- Typical findings include bilateral eyelid edema, chemosis, and copious purulent discharge. Onset may be on the 1st day of life, if prolonged rupture of membranes has occurred, or as late as several weeks of age.
- Neonatal scalp abscess:
- Complication of fetal scalp monitoring
- Cervical motion tenderness:
- Signs of pelvic inflammatory disease include cervical motion tenderness, pelvic adnexal tenderness (usually bilateral), and lower or right upper quadrant abdominal pain (with perihepatitis). Most women with pelvic inflammatory disease also have either mucopurulent cervical discharge or WBCs on microscopic evaluation of a saline preparation of vaginal fluid.
- Purulent vaginal discharge:
- Common in both cervicitis and urethritis. Associated bacterial vaginosis may be noted.
Gonococcal Infections - tests
Gonococcal Infections - lab
- Neonate: Hospitalize and obtain appropriate cultures (blood, CFS, conjunctival fluids, or those from any other site of infection).
- Gram stain and culture of infected exudate or body fluid:
- Intracellular Gram-negative diplococci on gram stain. Confirmation depends on isolation of N. gonorrhoeae from culture. The specimens are inoculated onto Thayer-Martin or chocolate-blood agar-based media at room temperature and promptly incubated in an enriched CO
- STD panel:
- Test for other STDs in the child in whom sexual abuse is suspected or when evaluating the sexually active adolescent. This includes testing for Chlamydia trachomatis, Treponema pallidum (syphilis), Trichomonas vaginalis, and HIV.
- Nonculture gonococcal tests:
- DNA amplification by polymerase chain reaction or ligase chain reaction (LCR) are comparable with culture in sensitivity and specificity, but should not be used in investigations of possible sexual abuse (owing to the possibility of false-positive results). In nonabuse cases, LCR may be performed on freshly voided urine (95% sensitivity, 100% specificity) and self-administered introital swabs.
- CBC, ESR, and C-reactive protein:
- Leukocytosis and elevated ESR and C-reactive protein occur in 2/3 of patients with pelvic inflammatory disease.
- Synovial fluid cell count and culture:
- In septic gonococcal arthritis, synovial fluid has >50,000 leukocytes/mm3 and the synovial fluid culture is positive, whereas the blood culture is usually negative. In arthritis-dermatitis syndrome, the synovial fluid contains <20,000 leukocytes/mm3, and the synovial fluid culture is sterile, whereas the blood culture is positive.
Gonococcal Infections - imaging
Pelvic ultrasound may detect ectopic pregnancy and in pelvic inflammatory disease reveals thick, dilated fallopian tubes or tubo-ovarian abscess.
Gonococcal Infections - differencial diagnosis
- Ophthalmia neonatorum: Other causes of neonatal conjunctivitis include infection with C. trachomatis, S. aureus, S. pneumoniae, Haemophilus species, and herpes simplex virus.
- Scalp infection: Gonococcal scalp abscesses may be difficult to distinguish from abscesses caused by staphylococcal species, group B Streptococcus, H. influenzae, Enterobacteriaceae, and herpes simplex virus.
- Vaginitis: In the prepubertal child, other causes include chemical or environmental irritants, pinworms, foreign body, and infections (i.e., streptococci, other bacteria, 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, and UTI
Gonococcal Infections - TREATMENT
Gonococcal Infections - medication
- 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 the mucopurulent drainage has ceased.
- Disseminated infection: Ceftriaxone daily or cefotaxime b.i.d. for 7 days; continue treatment for 10–14 days for meningitis.
- Older children and adolescents:
- Uncomplicated gonococcal infection: A single IM dose of ceftriaxone (50 mg/kg; maximum 1 g), or a PO dose of ciprofloxacin (500 mg), ofloxacin (400 mg), or azithromycin (20 mg/kg; maximum, 1 g). Follow with a treatment regimen for C. trachomatis.
- Pelvic inflammatory disease: See Pediatric Red Book for treatment regimens.
- Disseminated gonococcal infection: Ceftriaxone for 7 days (arthritis), 14 days (meningitis), or 28 days (endocarditis). For arthritis, add erythromycin, azithromycin, or doxycycline for 7 days. For meningitis or endocarditis, add erythromycin for 7 days.
Gonococcal Infections - FOLLOW UP
- Sexual contacts of patients with gonorrhea should be counseled and treated.
- Evaluate for concurrent infection with other sexually transmitted diseases, including syphilis, C. trachomatis, T. vaginalis, 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 recommended for all hospitalized patients with gonococcal disease in the neonatal and prepubescent age groups; no special policies are recommended for other patients.
Pitfalls:
- Failure to consider the diagnosis of sexual abuse in a child with a gonococcal infection after the neonatal period. Cases of transmission via nonsexual contact have been reported (i.e., from freshly infected towels, or other fomites, or by digital transmission from an infected caregiver), but such mode cannot be assumed without 1st excluding sexual abuse.
- Use DNA amplification methods instead of culture to diagnose infection in cases of suspected abuse.
- Failure to differentiate N. gonorrhoeae by culture from other Neisseria species, especially in prepubertal children, owing to the underlying question of child sexual abuse
- Failure to consider the diagnosis of acute gonococcal perihepatitis in females with right upper quadrant pain
- Classic findings of fever, leukocytosis, and elevated erythrocyte sedimentation rate or C-reactive protein are not found in 1/3 of patients with pelvic inflammatory disease that has been documented laparoscopically.
Gonococcal Infections - prognosis
Prognosis has also been improved by treating all forms of infection with a 3rd-generation cephalosporin owing to the increased prevalence of penicillin-resistant N. gonorrhoeae.
Gonococcal Infections - complications
- Gonococcal infection during pregnancy:
- Gonococcal pelvic inflammatory disease is associated with spontaneous abortion, preterm labor, and perinatal infant mortality.
- Ophthalmia neonatorum of gonococcal origin may rapidly progress to corneal ulceration and perforation, with subsequent scarring and blindness.
- Pelvic inflammatory disease:
- Endometritis, salpingitis, tubo-ovarian 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.
- A woman’s risk of ectopic pregnancy increases sevenfold after one episode of pelvic inflammatory disease.
- In males, rare complications include periurethral abscess, acute prostatitis, seminal vesiculitis, and urethral strictures.
- Disseminated disease:
- Occurs via hematogenous dissemination of infection
- Patients with multiple episodes of disseminated gonococcal infection should be tested for complement deficiency.
- In neonates, arthritis is the most frequent systemic manifestation of gonococcal disease. Symptoms develop 1–4 weeks after delivery. Involvement of multiple joints is typical, and most of these infants so affected have no evidence of ophthalmia neonatorum.
- In older children and adolescents, septic arthritis (one joint) and a characteristic syndrome of polyarthritis (multiple joints) dermatitis are predominant manifestations.
- Gonococcal meningitis, endocarditis, and osteomyelitis are rare in children.
Gonococcal Infections - bibliography
American Academy of Pediatrics. Pelvic inflammatory disease. In: Pickering LK, ed: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:493–498.- Darville T. Chlamydia trachomatis infections in neonates and young children. Semin Pediatr Infect Dis. 2005;16:235–244.
- Hollier LM, Workowski K. Treatment of sexually transmitted diseases in women. Obstet Gynecol Clin North Am. 2003;30:751–775, vii–viii.
- Ingram DM, Miller WC, Schoenbach VJ, et al. Risk assessment for gonococcal and chlamydial infections in young children undergoing evaluation for sexual abuse. Pediatrics. 2001;107:e73.
- Koumans EH, Johnson RE, Knapp JS, et al. Laboratory testing for Neisseria gonorrhoeae by recently introduced nonculture tests: A performance review with clinical and public health considerations. Clin Infect Dis. 1998;27:1171–1180.
- Moran J. Gonorrhoea. Clin Evidence. 2002;1437–1444.
Gonococcal Infections - CODES
Gonococcal Infections - icd9
098.0 Gonococcal infections, acute, of lower genitourinary tract
Gonococcal Infections - FAQ
- Q: What are the advantages of the nucleic amplification tests for making a diagnosis?
- A: The TMA test (transcription mediated amplification test) of urine samples, approved by the FDA for women, can be used to test for Cl Trachotis and N. gonorrhea.
- Q: When is this test not approved?
- A: For rectal and pharyngeal swabs and for cases of suspected abuse.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Urethral Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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