Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

---

1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Gonococcal Infections Among Infants
     
     Gonococcal infection among neonates usually results from
peripartum exposure to infected cervical exudate of the mother.
Gonococcal infection among neonates is usually an acute illness
beginning 2-5 days after birth. The incidence of N. gonorrhoeae
among neonates varies in U.S. communities, depends on the
prevalence of infection among pregnant women, on whether pregnant
women are screened for gonorrhea, and on whether newborns receive
ophthalmia prophylaxis. The prevalence of infection is less than 1%
in most prenatal patient populations, but may be higher in some
settings.

     Of greatest concern are complications of ophthalmia neonatorum
and sepsis, including arthritis and meningitis. Less serious
manifestations at sites of infection include rhinitis, vaginitis,
urethritis, and inflammation at sites of intrauterine fetal
monitoring.

Ophthalmia Neonatorum Caused by N. gonorrhoeae
     In most patient populations in the United States, C.
trachomatis and nonsexually transmitted agents are more common
causes of neonatal conjunctivitis than N. gonorrhoeae. However, N.
gonorrhoeae is especially important because gonococcal ophthalmia
may result in perforation of the globe and in blindness.

Diagnostic Considerations
     Infants at high risk for gonococcal ophthalmia in the United
States are those who do not receive ophthalmia prophylaxis, whose
mothers have had no prenatal care, or whose mothers have a history
of STDs or substance abuse. The presence of typical Gram-negative
diplococci in a Gram-stained smear of conjunctival exudate suggests
a diagnosis of N. gonorrhoeae conjunctivitis. Such patients should
be treated presumptively for gonorrhea after obtaining appropriate
cultures for N. gonorrhoeae; appropriate chlamydial testing should
be done simultaneously. The decision not to treat presumptively for
N. gonorrhoeae among patients without evidence of gonococci on a
Gram-stained smear of conjunctival exudate, or among patients for
whom a Gram-stained smear cannot be performed, must be made on a
case-by-case basis after considering the previously described risk
factors.

     A specimen of conjunctival exudate also should be cultured for
isolation of N. gonorrhoeae, since culture is needed for definitive
microbiologic identification and for antibiotic susceptibility
testing. Such definitive testing is required because of the public
health and social consequences for the infant and mother that may
result from the diagnosis of gonococcal ophthalmia. Moraxella
catarrhalis and other Neisseria species are uncommon causes of
neonatal conjunctivitis that can mimic N. gonorrhoeae on
Gram-stained smear. To differentiate N. gonorrhoeae from M.
catarrhalis and other Neisseria species, the laboratory should be
instructed to perform confirmatory tests on any colonies that meet
presumptive criteria for N. gonorrhoeae.

Recommended Regimen -
     Ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to
     exceed 125 mg.

NOTE: Topical antibiotic therapy alone is inadequate and is
unnecessary if systemic treatment is administered.

Other Management Considerations -
     Simultaneous infection with C. trachomatis has been reported
and should be considered for patients who do not respond
satisfactorily. The mother and infant should be tested for
chlamydial infection at the same time that gonorrhea testing is
done (see Ophthalmia Neonatorum Caused by C. trachomatis).
Ceftriaxone should be administered cautiously among infants with
elevated bilirubin levels, especially premature infants.

Follow-Up -
     Infants should be admitted to the hospital and evaluated for
signs of disseminated infection (e.g., sepsis, arthritis, and
meningitis). One dose of ceftriaxone is adequate for gonococcal
conjunctivitis, but many pediatricians prefer to maintain infants
on antibiotics until cultures are negative at 48-72 hours. The
decision on duration of therapy should be made with input from
experienced physicians.

Management of Mothers and Their Sex Partners -
     The mothers of infants with gonococcal infection and their sex
partners should be evaluated and treated following the
recommendations for treatment of gonococcal infections in adults
(see Gonococcal Infections Among Adolescents and Adults).

Disseminated Gonococcal Infection Among Infants
     Sepsis, arthritis, meningitis, or any combination thereof are
rare complications of neonatal gonococcal infection. Gonococcal
scalp abscesses also may develop as a result of fetal monitoring.
Detection of gonococcal infection among neonates who have sepsis,
arthritis, meningitis, or scalp abscesses requires cultures of
blood, CSF, and joint aspirate on chocolate agar. Cultures of
specimens from the conjunctiva, vagina, oropharynx, and rectum onto
gonococcal selective medium are useful to identify sites of primary
infection, especially if inflammation is present. Positive
Gram-stained smears of exudate, CSF, or joint aspirate provide a
presumptive basis for initiating treatment for N. gonorrhoeae.
Diagnoses based on positive Gram-stained smears or presumptive
isolation by cultures should be confirmed with definitive tests on
culture isolates.

Recommended Regimen -
     Ceftriaxone 25-50 mg/kg/day IV or IM in a single daily dose
     for 7 days, with a duration of 10-14 days, if meningitis is
     documented;
                        or
     Cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days, with
     a duration of 10-14 days, if meningitis is documented.

Prophylactic Treatment for Infants Whose Mothers Have Gonococcal
Infection
     Infants born to mothers who have untreated gonorrhea are at
high risk for infection.

Recommended Regimen in the Absence of Signs of Gonococcal Infection -
     Ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 mg, in a
     single dose.

Other Management Considerations -
     If simultaneous infection with C. trachomatis has been
reported, mother and infant should be tested for chlamydial
infection.

Follow-Up -
     Follow-up examination is not required.

Management of Mothers and Their Sex Partners -
     The mothers of infants with gonococcal infection and the
mother's sex partners should be evaluated and treated following the
recommendations for treatment of gonococcal infections among adults
(see Gonococcal Infections).

---