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Gonococcal infection in children
Last reviewed: 07.07.2025
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Gonococcal infection in neonates usually results from contact with infected maternal cervical secretions during labor. It usually develops as an acute illness on the 2nd to 5th day of life. The prevalence of gonococcal infection in neonates depends on the prevalence of infection in pregnant women, whether the pregnant woman was screened for gonorrhea, and whether the neonate was given ophthalmia prophylaxis.
The most serious complications are ophthalmia neonatorum and sepsis, including arthritis and meningitis. Less serious manifestations of local infection include rhinitis, vaginitis, urethritis and inflammation at the sites of intrauterine fetal monitoring.
Ophthalmia neonatorum 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 organisms, N. gonorrhoeae is a particularly important pathogen because gonococcal ophthalmia can lead to globe perforation and blindness.
Diagnostic Notes
In the United States, neonates at high risk for gonococcal ophthalmia include those who have not received ophthalmia prophylaxis, whose mothers were not followed prenatally, have a history of STDs, or were raped. Based on the identification of typical gram-negative diplococci in a Gram-stained specimen of conjunctival exudate, gonococcal conjunctivitis is diagnosed and treated after appropriate culture; appropriate testing for chlamydia should be done simultaneously. Prophylactic treatment for gonorrhea may be indicated in neonates with conjunctivitis in whom gonococci are negative for Gram-stained conjunctival exudate if they have any of the risk factors noted above.
In all cases of neonatal conjunctivitis, conjunctival exudate should also be examined to isolate N. gonorrhoeae for identification and to perform antibiotic susceptibility testing. Accurate diagnosis is important for public health and because of the social consequences of gonorrhoea. Nongonococcal causes of neonatal ophthalmia, including Moraxella catarrahalis and other Neisseria species, are difficult to distinguish from N. gonorrhoeae by Gram stain but can be differentiated in the microbiology laboratory.
Gonococcal infection in children
After the neonatal period, sexual abuse is the most common cause of gonococcal infection in preadolescents (see Child Sexual Abuse and Rape). Preadolescents typically present with gonococcal infection as vaginitis. PID resulting from vaginal infection is less common than in adults. Sexually abused children often have anorectal and pharyngeal gonococcal infection, which is usually asymptomatic.
Diagnostic Notes
Only standard culture should be used to isolate N. gonorrhoeae from children. Nonculture tests for gonorrhea, including Gram stain, DNA probes, or ELISA without culture should not be used; none of these tests have been approved by the FDA for testing oropharyngeal, rectal, or genital tract specimens in children. Vaginal, urethral, pharyngeal, or rectal specimens should be tested on selective media for the isolation of N. gonorrhoeae. All suspected isolates of N. gononhoeae should be positively identified by at least two tests based on different principles (eg, biochemical, serologic, or enzyme assays). Isolates should be retained for additional or repeat testing.
Recommended regimens for children weighing > 45 kg
Children weighing >45 kg should be treated according to one of the regimens recommended for adults (see Gonococcal infection).
Quinolones are not recommended for use in children because they have been shown to be toxic in animal studies. However, studies of children with cystic fibrosis treated with ciprofloxacin have shown no adverse effects.
Recommended regimen for children weighing less than 45 kg with uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
Ceftriaxone 125 mg intramuscularly once
Alternative scheme
Spectinomycin 40 mg/kg (maximum 2 g) IM in a single dose may be used but is unreliable against pharyngeal infection. Some authorities use cefixime in children because it can be given orally, but there are no published reports on its safety or effectiveness in such cases.
Recommended regimen for children weighing less than 45 kg with bacteremia or arthritis
Ceftriaxone 50 mg/kg (maximum 1 g) IM or IV once daily for 7 days.
Recommended regimen for children weighing > 45 kg with bacteremia or arthritis
Ceftriaxone 50 mg/kg (maximum 2 g) IM or IV once daily for 10-14 days.
Follow-up observation
Culture verification of cure is not indicated if ceftriaxone has been administered. When treating with spectinomycin, a control culture is necessary to confirm efficacy.
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Recommended treatment regimen for gonorrhea
Ceftriaxone 25-50 mg/kg IV or IM once, no more than 125 mg
Local antibiotic therapy alone is ineffective and is not necessary if systemic treatment is used.
Special considerations for patient management
The possibility of co-infection with C. trachomatis should be considered in patients who fail treatment. Mothers and their infants should be tested for chlamydial infection at the same time as testing for gonorrhoea (see Ophthalmia neonatorum due to C. trachomatis). Particular caution should be exercised when administering ceftriaxone to infants with elevated bilirubin, particularly premature infants.
Follow-up observation
A neonate diagnosed with gonococcal ophthalmia should be hospitalized and evaluated for signs of disseminated infection (eg, sepsis, arthritis, and meningitis). A single dose of ceftriaxone is sufficient to treat gonococcal conjunctivitis, but some pediatricians prefer to give children antibiotics for 48 to 72 hours until culture results are negative. The decision on the duration of treatment should be made in consultation with an experienced physician.
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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 rare complications of gonococcal infection in neonates. Scalp abscesses may also develop as a result of blanket monitoring. Diagnosis of gonococcal infection in neonates with sepsis, arthritis, meningitis, or scalp abscess requires chocolate agar culture of blood, CSF, and joint aspirate. Gonococcal-selective culture of conjunctival, vaginal, oropharyngeal, and rectal specimens may indicate the primary site of infection, particularly if inflammation is present. Positive Gram stains of exudate, CSF, or joint aspirate warrant treatment for gonorrhea. Diagnosis based on a positive Gram stain or tentative culture identification should be confirmed by specific tests.
Recommended schemes
Ceftriaxone 25-50 mg/kg/day IV or IM once for 7 days, if the diagnosis of meningitis is confirmed - for 10-14 days,
Or Cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days, if the diagnosis of meningitis is confirmed - for 10-14 days.
Preventive treatment of newborns whose mothers have gonococcal infection
Children born to mothers with untreated gonorrhea are at high risk of contracting the infection.
Recommended regimen in the absence of signs of gonococcal infection
Ceftriaxone 25-50 mg/kg intravenously or intramuscularly, but not more than 125 mg, once.
Other considerations for patient management
Mothers and infants should be tested for chlamydial infection.
Follow-up observation
No follow-up is required.
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 considerations for patient management
In children, only parenteral cephalosporins are recommended. Ceftriaxone is used to treat all gonococcal infections in children; cefotaxime is used only for gonococcal ophthalmia. Oral cephalosporins (cefixime, cefuroxime axetil, cefpodoxime axetil) have not been adequately evaluated in the treatment of gonococcal infections in children to recommend their use.
All children with gonococcal infection should be tested for co-infection with syphilis or chlamydia. For a discussion of sexual abuse, see Child Sexual Abuse and Rape.
More information of the treatment
Prevention of ophthalmia neonatorum
Instillation of a prophylactic agent into the eyes of newborn infants to prevent gonococcal ophthalmia neonatorum is required by law in most states. All of the regimens listed below are effective in preventing gonococcal ophthalmia neonatorum. However, their effectiveness against chlamydial ophthalmia has not been established and they do not prevent nasopharyngeal colonization with C. trachomatis. Diagnosis and treatment of gonococcal and chlamydial infections in pregnant women is the best method for preventing gonococcal and chlamydial infections in neonates. However, not all women receive prenatal care. Therefore, prophylaxis against gonococcal ophthalmia neonatorum is warranted because it is safe, simple, inexpensive, and may prevent vision-threatening disease.
Recommended drugs
- Silver nitrate (1%), aqueous solution, single application,
- or Erythromycin (0.5%), eye ointment, single application,
- or Tetracycline (1%), eye ointment, single application.
One of the above medications should be administered to both eyes of each newborn immediately after birth. If prophylaxis cannot be given immediately (in the delivery room), the facility should have a monitoring system to ensure that all newborns receive prophylaxis. Prophylaxis against eye infection should be given to all newborns, regardless of whether the birth was vaginal or cesarean section. Disposable tubes or ampoules are preferred over reusable ones. Bacitracin is not effective. Povidone iodine has not been adequately studied.