Gonococcal Infections in Neonates and Young Children

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Gonorrhea has been recognized since antiquity, and more than 60 million new cases occur yearly worldwide. Much has been learned about the molecular pathogenesis of infection by Neisseria gonorrhoeae, but immunity from natural infection does not protect against reinfection with the same strain, and the goal of a protective vaccine remains elusive. Gonococcal ophthalmia neonatorum is the most common manifestation in infants born to mothers with gonococcal genital tract infections. Genital and pharyngeal gonococcal infections in young children almost always are acquired from sexual abuse by an infected adult. Invasive disease can occur at any age but is uncommon. Nonculture diagnostic tests are widely used in adults, but culture is required in children for medicolegal purposes. N. gonorrhoeae strains have developed resistance to many antibiotic classes, and resistance profiles vary among geographic regions and within regions over time. Current guidelines for treatment of gonococcal infections in children in the United States are reviewed.

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Epidemiology of Gonococcal Infection

Rates of gonococcal infections in the United States (Fig. 1) and Western Europe have declined in the past 20 years, but an estimated 62.35 million new cases of gonococcal infections occurred worldwide in 1999, almost half of which were in South and Southeast Asia and another quarter in sub-Saharan Africa.6 In 2003, 335,104 cases were reported in the United States, yielding a rate of 116.2/100,000 population.7 The Healthy People 2010 national goal in the United States is 19 per 100,000.

Microbiology

Neisseria spp. are aerobic, gram-negative, nonmotile, and nonsporeforming. Gonococci occur in pairs (diplococci), with adjacent sides flattened, and have an outer membrane overlying a thin peptidoglycan layer and cytoplasmic membrane that is typical of gram-negative bacteria. The species lacks a true polysaccharide capsule but produces a surface polyphosphate that provides a hydrophilic, negatively charged surface.22 The microbes frequently are seen within phagocytes in Gram stains of clinical

Pathogenesis

Gonococci are able to survive in the urethra in the face of hydrodynamic forces that tend to wash other microbes away, suggesting an ability to adhere to mucosal epithelial cells. They are able to persist despite generating an intense influx of neutrophils, which indicates capacity to evade the host acute innate immune response. Individuals also can have repeated infections with the same gonococcal strain, suggesting the occurrence of frequent antigenic variations that thwart established local

Perinatal Gonococcal Infections

Among pregnant women with gonococcal infection, 13 percent will experience septic abortion, 23 percent will deliver prematurely (approximately one-third of these infants will die), and 29 percent will have premature rupture of the membranes. Recognition of gonorrhea early in pregnancy identifies a population at risk that should be followed for potential reinfection throughout pregnancy.59, 60 Adolescent girls have a higher prevalence of gonorrhea than do older women of childbearing age, which

Genital Tract Infection in Prepubertal Girls

Gonococcal vaginitis or vulvovaginitis is the most common form of gonorrhea found in prepubertal girls. The prepubertal anestrogenic vaginal mucosa creates an alkaline environment that is more readily colonized and infected on exposure to N. gonorrhoeae than is that of postpubertal girls. Infection of the endocervix, urethra, paraurethral and Bartholin glands, and upper genital tract rarely occur. Gonococcal vaginitis in prepubertal girls almost always is symptomatic, with vulvar erythema and a

Diagnostic Testing

Isolation of N. gonorrhoeae in culture remains the standard for diagnosis of gonococcal infections, but nonculture DNA-based tests have become widely used in recent years. Only culture should be used for rectal or pharyngeal specimens. Serologic tests are of limited clinical utility because of low sensitivity (approximately 70%).82 Because gonococci cannot tolerate drying, inoculating clinical specimens onto appropriate media as soon as possible is important. Transport bottles that contain

Treatment

Gonococcal antimicrobial susceptibility patterns are ever changing and can vary widely across and within different geographic regions. Healthcare providers must remain alert for modifications of treatment guidelines for their respective geographic locations. In the United States in 2003, 16.4 percent of gonococcal isolates evaluated by the Gonococcal Isolate Surveillance Project were resistant to penicillin, tetracyclines, or both.7 Spectinomycin resistance currently is a rare occurrence.

Gonococcal Infection and Sexual Abuse of Children

Approximately 10 percent of girls suffer sexual abuse during childhood, and rates in male children appear to be approximately 3 percent.94, 95 When gonococcal infection is identified in a prepubertal child, sexual abuse must be considered highly likely—nonsexual transmission should never be assumed without extensive investigation of the social setting of an infected child.65, 96 STDs overall are found in only 3 to 20 percent of sexually abused children,76, 97, 98 such that the absence of STDs

Prevention and Control of Gonococcal Infections

All cases of gonococcal infection must be reported to public health officials. Efforts should be made to evaluate, counsel, and treat all sexual contacts of the adult who is the source of gonococcal infection in a child. When patients with gonococcal infections are hospitalized, standard precautions are recommended. This measure includes infants with GON.65

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