Gonococcal infection in children

Gonococcal infection in newborns is usually the result of contact with infected secretions from the cervix in the mother during childbirth. Usually it develops as an acute illness on the 2-5th day of life. The prevalence of gonococcal infection in newborns depends on the prevalence of infection in pregnant women, because whether the pregnant woman has screened for gonorrhea and whether the newborn has had ophthalmia prophylaxis.

The most serious complications are neonatal ophthalmia and sepsis, including arthritis and meningitis. Less severe manifestations of local infection include rhinitis, vaginitis, urethritis and inflammation at the sites of intrauterine monitoring of the fetus.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Ophthalmia of newborns caused by N. Gonorrhoeae

Although N. Gonorrhoeae is a less common cause of neonatal conjunctivitis in the United States than C. Trachomatis and other non-sexually transmitted microorganisms, however, N. Gonorrhoeae is a particularly important pathogen since gonococcal ophthalmia can lead to perforation of the eyeball and blindness.

Diagnostic notes

In the United States, those who are at high risk for gonococcal ophthalmia are those who have not received prophylaxis from ophthalmia, whose mothers were not seen in the prenatal period, had an STD in history, or were raped. Based on the identification of typical gram-negative diplococci in Gram-stained samples taken from conjunctival exudates, gonococcal conjunctivitis is diagnosed and treatment is selected after taking the material for the appropriate culture study; at the same time, appropriate studies should be conducted on Chlamydia. Prophylactic treatment of gonorrhea can be indicated in newborns with conjunctivitis who have not been found gonococci in a Gram stain smear from conjunctival exudate if they have any of the risk factors specified above.

In all cases of neonatal conjunctivitis, conjunctival exudate should also be examined to isolate N. Gonorrhoeae for identification and for antibiotic susceptibility testing. An accurate diagnosis is important for health authorities and because of the social consequences of gonorrhea. Non-gonococcal causes of neonatal ophthalmia, including Moraxella catarrahalis and other Neisseria species, are difficult to distinguish from N. Gonorrhoeae in Gram staining, but they can be differentiated in a microbiological laboratory.

[11], [12], [13], [14], [15]

Gonococcal infection in children

After the neonatal period, sexual abuse is the most common cause of gonococcal infection in pre-adulthood children (see Sexual abuse of children and rape). As a rule, gonococcal infection in children of preadolescence is manifested in the form of vaginitis. PID as a result of infection of the vagina is observed less often than in adults. Udetey, subjected to sexual abuse, often has anorectal and pharyngeal gonococcal infection, which usually proceeds asymptomatically.

Diagnostic notes

To isolate N. Gonorrhoeae in children, only the standard culture method should be used. Non-cultural tests for gonorrhea, including Gram staining, DNA probes or ELISA without culture examination should not be used; none of these tests was approved by the FDA for the study of samples from the oropharynx, rectum or genital tract in children. Samples from the vagina, urethra, pharynx or rectum should be examined on selective media for the isolation of N. Gonorrhoeae. All putative isolates of N. Gononhoeae should be accurately identified, at least by two tests based on different principles, (for example, biochemical properties, serological or determination of enzymes of the pathogen). Isolates must be preserved for additional or repeated testing.

[16], [17]

Recommended regimens for children with a body weight> 45 kg

Children with a body weight> 45 kg should receive treatment according to one of their regimens recommended for adults (see Gonococcal infection).

Quinolones are not recommended for use in children. Their toxicity was noted in animal studies. However, studies of children with cystic fibrosis who were treated with ciprofloxacin did not show its side effects.

Recommended scheme for children weighing less than 45 kg with uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis

Ceftriaxone 125 mg IM once

Alternative scheme

Spectinomycin 40 mg / kg (maximum 2 g) IM in a single dose can be used, but it is unreliable against pharyngeal infection. Some specialists use cefixime to treat children, because it can be administered orally, however, there are no published reports on its safety or efficacy in treating such cases.

Recommended scheme for children weighing less than 45 kg with bacteremia or arthritis

Ceftriaxone 50 mg / kg (maximum 1 g) IM or IV once a day, daily for 7 days.

Recommended scheme for children with a body weight> 45 kg with bacteremia or arthritis

Ceftriaxone 50 mg / kg (maximum 2 g) IM or IV once a day, daily for 10-14 days.

Follow-up

Cultural control of cure, if ceftriaxone was prescribed, is not shown. In the treatment of spectinomycin, a control culture test is necessary to confirm the effectiveness.

[18], [19], [20], [21]

[22], [23]

The recommended regimen for the treatment of gonorrhea

Ceftriaxone 25-50 mg / kg iv or IM once, not more than 125 mg

Only local antibiotic therapy is ineffective and it is not necessary if systemic treatment is used.

Special notes on managing patients

It should be considered the possibility of simultaneous infection of C. Trachomatis in patients in whom treatment has failed. Mothers and their children should be tested for chlamydial infection simultaneously with testing for gonorrhea (see Ophthalmia of newborns caused by C. Trachomatis). When prescribing ceftriaxone to children with elevated bilirubin and, especially, prematurely, special care should be taken.

Follow-up

A newborn who has gonococcal ophthalmia diagnosed must be hospitalized and examined for signs of disseminated infection (eg, sepsis, arthritis and meningitis). A single dose of ceftriaxone is sufficient for the treatment of gonococcal conjunctivitis, but some pediatricians prefer to give the children antibiotics within 48-72 hours before receiving negative cultivation results. The decision on the duration of treatment should be taken after consultation with an experienced doctor.

[24], [25], [26], [27], [28], [29], [30], [31], [32]

Management of mothers and their sexual partners

Mothers of children with gonococcal infection and their sexual partners should be examined and treated according to the regimens recommended for adults (see Gonococcal infection in adolescents and adults).

Sepsis, arthritis, meningitis or a combination of these are a rare complication of gonococcal infection in newborns. Also, abscesses of the scalp can develop as a result of monitoring the life span of the rug. For the diagnosis of gonococcal infection in newborns with sepsis, arthritis, meningitis or scalp abscess, a culture test of the blood, CSF and articular aspirate using chocolate agar is necessary. The cultivation of specimens obtained from the conjunctiva, from the vagina, from the oropharynx and rectum, on selective for the gonococcus environment can indicate the primary focus of infection, especially if there is inflammation. Positive results in Gram stain smears from exudate, CSF or articular aspirate are the basis for the initiation of gonorrhea treatment. The diagnosis based on positive results of Gram stain smearing or on the preliminary identification of culture should be confirmed by specific tests.

Recommended schemes

Ceftriaxone 25-50 mg / kg / day IV or IM once a day for 7 days if confirmed diagnosis of meningitis - within 10-14 days,

Or Cefotaxime 25 mg / kg IV or IM every 12 hours for 7 days if confirmed diagnosis of meningitis - within 10-14 days.

Preventive treatment of newborns whose mothers are ill with gonococcal infection

Children born to mothers with untreated gonorrhea are at high risk of this infection.

The recommended scheme in the absence of signs of gonococcal infection

Ceftriaxone 25-50 mg / kg IV or IM, but not more than 125 mg, once.

Other observations on patient management

Mothers and babies should be tested for chlamydial infection.

Follow-up

Follow-up monitoring is not required.

[33], [34]

Management of mothers and their sexual partners

Mothers of children with gonococcal infection and their sexual partners should be examined and treated according to the regimens recommended for adults (see Gonococcal infection).

Other observations on patient management

Children should only use parenteral cephalosporins. Ceftriaxone is used to treat all gonococcal infections in children; cefotaxime - only for gonococcal ophthalmia. Oral cephalosporins (cefixime, cefuroxime axetil, cefpodoxime axetil) have not been adequately evaluated in the treatment of gonococcal infections in children so that their use can be recommended.

All children with gonococcal infection should be examined for a mixed infection with syphilis or chlamydia. For sexual abuse, see Sexual abuse of children and rape.

Prevention of ophthalmia of newborns

The installation of a prophylactic drug in the eyes of newborn infants to prevent gonococcal neonatal ophthalmia is required by law in most states. All the regimens listed below are effective for the prevention of gonococcal infection of the eye. However, their efficacy against chlamydial ophthalmia is not established and they do not prevent the nasopharyngeal colonization of C. Trachomatis. Diagnosis and treatment of gonococcal and chlamydial infections in pregnant women is the best method for preventing gonococcal and chlamydial diseases in newborns. However, not all women receive prenatal care. Therefore, the prevention of gonococcal infection of the eyes is justified, because it is safe, simple, inexpensive, and can prevent a vision-threatening disease.

Recommended drugs

• Silver nitrate (1%), aqueous solution, single application,
• or Erythromycin (0.5%), ophthalmic ointment, single application,
• or Tetracycline (1%), ophthalmic ointment, single application.

One of the above drugs must be introduced into both eyes to each newborn immediately after birth. If prophylaxis can not be carried out immediately (in the birth chamber), a medical system should be established in the medical institution to ensure that all newborns receive preventive treatment. Prevention of ocular infection should be performed in all newborns, regardless of whether the birth was natural or a cesarean section was performed. The use of disposable tubes or ampoules is preferable to reusable tubes. Bacitracin is not effective. Povidone iodine has not been studied enough.