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.
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.
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.
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.
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:
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.
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:
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.
Symptomatic or High-Risk (mother with untreated gonorrhea) neonate
Non-Neonate with Symptoms (generally, can be managed on an outpatient basis)
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.
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. (Level V)
|||Lessing JN,Slingsby TJ,Betz M, Hyperacute Gonococcal Keratoconjunctivitis. Journal of general internal medicine. 2019 Jan 16; [PubMed PMID: 30652276]|
|||Tan AK, Ophthalmia Neonatorum. The New England journal of medicine. 2019 Jan 10; [PubMed PMID: 30625059]|
|||Fiorito TM,Noor A,Silletti R,Krilov LR, Neonatal Conjunctivitis Caused by Neisseria cinerea: A Case of Mistaken Identity. Journal of the Pediatric Infectious Diseases Society. 2018 Nov 21; [PubMed PMID: 30462276]|
|||Kaštelan S,Anić Jurica S,Orešković S,Župić T,Herman M,Gverović Antunica A,Marković I,Bakija I, A Survey of Current Prophylactic Treatment for Ophthalmia Neonatorum in Croatia and a Review of International Preventive Practices. Medical science monitor : international medical journal of experimental and clinical research. 2018 Nov 10; [PubMed PMID: 30413681]|
|||Belga S,Gratrix J,Smyczek P,Bertholet L,Read R,Roelofs K,Singh AE, Gonococcal Conjunctivitis in Adults: Case Report and Retrospective Review of Cases in Alberta, Canada, 2000-2016. Sexually transmitted diseases. 2019 Jan; [PubMed PMID: 30044333]|
|||Churchward CP,Calder A,Snyder LAS, Mutations in Neisseria gonorrhoeae grown in sub-lethal concentrations of monocaprin do not confer resistance. PloS one. 2018; [PubMed PMID: 29621310]|
|||Gallenga PE,Del Boccio M,Gallenga CE,Neri G,Pennelli A,Toniato E,Lobefalo L,Maritati M,Perri P,Contini C,Del Boccio G, Diagnosis of a neonatal ophthalmic discharge, Ophthalmia neonatorum, in the molecular age: investigation for a correct therapy. Journal of biological regulators and homeostatic agents. 2018 Jan-Feb; [PubMed PMID: 29504385]|
|||Gonçalves Dos Santos Martins T,Fontes de Azevedo Costa AL, A rare ocular complication of neisseria gonorrhoeae. Irish journal of medical science. 2018 Aug; [PubMed PMID: 29349557]|
|||Hammerschlag MR,Smith-Norowitz T,Kohlhoff SA, Keeping an Eye on Chlamydia and Gonorrhea Conjunctivitis in Infants in the United States, 2010-2015. Sexually transmitted diseases. 2017 Sep; [PubMed PMID: 28809776]|
|||Pak KY,Kim SI,Lee JS, Neonatal Bacterial Conjunctivitis in Korea in the 21st Century. Cornea. 2017 Apr; [PubMed PMID: 28002109]|
|||Bodurtha Smith AJ,Holzman SB,Manesh RS,Perl TM, Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission. Journal of pediatric and adolescent gynecology. 2017 Aug; [PubMed PMID: 27871917]|
|||Zuppa AA,D'Andrea V,Catenazzi P,Scorrano A,Romagnoli C, Ophthalmia neonatorum: what kind of prophylaxis? The journal of maternal-fetal [PubMed PMID: 21534852]|