Neonatal Gonococcal Ophthalmia -- California

A case of neonatal gonococcal ophthalmia has been reported to CDC from San Diego, California. The ophthalmia occurred even though the neonate received ocular prophylaxis with erythromycin.

In late June, a male infant, of normal weight for gestational age, was born to a primiparous mother after a full-term, uncomplicated pregnancy. The mother had received prenatal care at a local health center since the end of the first trimester. She had been seen nine times during the pregnancy. Specimens for VDRL and gonorrhea cultures had been obtained in February 1983; both tests were reported as negative. The father had been seen at the clinic of a naval air station, diagnosed as having gonorrhea, and treated 9 days before the infant's birth. The mother was not contacted for either evaluation or treatment at that time.

One day before delivery, the mother visited the health center with uterine contractions but was not considered to be in active labor. A yellow-green, slightly odorous discharge was noted at the vaginal introitus. Cultures were taken, and she was referred to the affiliated hospital, with a diagnosis of possible rupture of membranes. No antibiotics were administered.

She was admitted on the following day to the obstetric ward in active labor, with spontaneous rupture of membranes and a copious green vaginal discharge. Two hours later, an internal fetal monitor was applied. Six hours and 35 minutes later, a lightly meconium-stained infant was delivered vaginally, vertex posterior presentation. Apgar scores were 6 at 1 minute and 9 at 5 minutes. The infant's eyes were treated with erythromycin ophthalmic ointment about 5 minutes after delivery. The newborn examination was described as normal.

Approximately 24 hours after birth, the results of the cultures obtained from the mother the day before delivery were reported as positive for a gram-negative, oxidase-positive organism, eventually confirmed as Neisseria gonorrhoeae. The mother was treated with procaine penicillin, 4.8 million units intramuscularly (IM) and probenecid 1 g orally. Blood and cerebrospinal fluid for culture were obtained from the infant, and he was treated with 200,000 units of benzathine penicillin (50,000 units/kg). Both cultures were subsequently negative. At 2 days of age, the infant developed a copious yellowish discharge from both eyes, along with ocular swelling and redness. Gram-stain smear of the exudate revealed gram-negative diplococci, subsequently confirmed as N. gonorrhoeae, B-lactamase negative. He was treated with aqueous penicillin, 50,000 units/kg intravenously (IV), for 7 days. In addition, his eyes were washed with saline every 30 minutes to 1 hour, and tetracycline eye ointment was instilled after each saline irrigation. The infant's eyes gradually improved over the next 2-3 days. Topical therapy was maintained for 5 days. Examination by an ophthalmologist revealed no corneal damage. The infant was subsequently seen as an outpatient; he had no apparent eye damage. One week after delivery, the mother was readmitted for endometritis culture-positive for N. gonorrhoeae, B-lactamase negative, demonstrating the severity of her infection. She responded to treatment with IV antibiotics. Reported by R Coen, MD, Dept of Pediatrics, University of California at San Diego, Venereal Disease Control Unit, Infectious Disease Section, California Dept of Health Svcs; Operational Research Br, Div of Venereal Disease Control, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This is the first case brought to the attention of CDC of gonococcal ophthalmia caused by nonpenicillinase-producing N. gonorrhoeae that occurred despite the use of erythromycin ophthalmic ointment. Recent reports have shown that penicillinase-producing N. gonorrhoeae can cause gonococcal ophthalmia despite prophylaxis with silver nitrate (1). No cases of penicillinase-production N. gonorrhoeae (PPNG) ophthalmia have been reported with erythromycin prophylaxis. The PPNG-ophthalmia neonatorum cases have occurred with either silver nitrate or no prophylaxis.

Several risk factors associated with this case may have reduced the efficacy of prophylactic use of erythromycin ointment. Prolonged rupture of membranes is more frequently associated with gonococcal ophthalmia than with other forms of ophthalmia (2). The interval between rupture of membranes and delivery may have been anywhere from 7 to 24 hours. The description of "yellow-green, slightly odorous discharge" on the day before the delivery is compatible with an established infection. The lower 1 minute Apgar score and light meconium staining noted after birth may have indicated mild distress before delivery, suggesting that an infection was already present. The incubation period of gonorrhea in neonates is 1-5 days. Therefore, the newborn examination within 24 hours after birth would not normally be expected to detect an early infection. In fact, documented cases of gonococcal eye infection have occurred even with minimal inflammatory responses (3).

Prophylaxis against ophthalmia with either silver nitrate or erythromycin ointment is not adequate for treatment of an already established gonococcal infection. In one study (2), 44 of 46 cases of gonococcal ophthalmia occurred despite silver nitrate prophylaxis. Investigators in this study also found that chlamydia ophthalmia was the most common specific type of ophthalmia neonatorum in their study, occurring in 86 of 302 cases. Silver nitrate is not effective prophylaxis for chlamydia ophthalmia, but erythromycin ophthalmic ointment has been proven to prevent that disease (4).

In this case, gonococcal ophthalmia developed despite the use of topical erythromycin ointment and IM benzathine penicillin. Current CDC recommendations are to treat infants born to mothers with gonococcal infection with aqueous crystalline penicillin G (5): 50,000 units IM or IV for full-term infants, or 20,000 units IM or IV for low-birth-weight infants. Documentation of prenatal care, cultures done during pregnancy, circumstances around labor and delivery, knowledge of the incidence of gonococcal infection in the local population, and other factors may help to delineate the choice of agents to be used under high-risk circumstances. The Division of Venereal Disease Control, CDC, encourages reporting of any known cases of neonatal gonococcal ophthalmia for further evaluation of the efficacy of the current recommendations for prophylaxis.

References

1. Doraiswamy B, Hammerschlag MR, Pringle GF, du Bouchet L. Ophthalmia neonatorum caused by B-lactamase-producing Neisseria gonorrhoeae. JAMA 1983;250:790-1.

2. Armstrong JH, Zacarias F, Rein MF. Ophthalmia neonatorum: a chart review. Pediatrics 1976;57:884-92.

3. Podgore JK, Holmes KK. Ocular gonococcal infection with minimal or no inflammatory response. JAMA 1981;246:242-3.

4. Hammerschlag MR, Chandler JW, Alexander ER, et al. Erythromycin ointment for ocular prophylaxis of neonatal chlamydial infection. JAMA 1980;244:2291-3.

5. MMWR. Sexually transmitted diseases treatment guidelines, 1982. 41S, 58S.

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