Treatment of gonococcal conjunctivitis in neonates and children

For neonates with mucopurulent conjunctivitis suspected to be caused by Neisseria gonorrhoeae (eg presence of risk factors for gonococcal infection in the birthing parent [eg mother]) in whom follow-up is likely to be difficult (eg in remote communities), take a conjunctival swab and consider starting empirical therapy for gonococcal conjunctivitis.

Gonococcal conjunctivitis in a child may result from birthing parent-to-child (eg mother-to-child) transmission, accidental transmission or sexual abuse (see also STIs in children).

Gonococcal conjunctivitis requires systemic treatment; topical antimicrobial therapy is not adequate. For adults with gonococcal conjunctivitis, azithromycin is used in combination with ceftriaxone to treat possible coinfection with Chlamydia trachomatis and to delay cephalosporin resistance in N. gonorrhoeae. For neonates and children with gonococcal conjunctivitis, monotherapy with ceftriaxone or cefotaxime is recommended; combination with azithromycin is only recommended if treatment for chlamydial conjunctivitis is also indicated, because azithromycin use in children younger than 6 weeks has been associated with the development of infantile hypertrophic pyloric stenosis (IHPS)Australian Society for Infectious Diseases (ASID), 2022Eberly, 2015.

While awaiting ophthalmology review, for neonates and children with gonococcal conjunctivitis in whom coinfection with C. trachomatis has been excluded, useAustralian Society for Infectious Diseases (ASID), 2022Workowski, 2021:

1ceftriaxone, as a single dose ceftriaxone ceftriaxone ceftriaxone

neonate: 50 mg/kg intramuscularly or intravenously1

child 1 month or older: 50 mg/kg up to 1 g intramuscularly2 or intravenously

OR

1cefotaxime, as a single dose cefotaxime cefotaxime cefotaxime

neonate: 100 mg/kg intramuscularly or intravenously

child 1 month or older: 50 mg/kg up to 1 g intramuscularly3 or intravenously.

For children who have had a nonsevere (immediate or delayed) or a severe immediate4 hypersensitivity reaction to a penicillin, while awaiting ophthalmology review, use ceftriaxone or cefotaxime at the dosages above.

For children who have had a severe delayed5 hypersensitivity reaction to a penicillin, seek expert advice.

Irrigate the eye with saline several times daily until purulence subsides. Immediately refer to an ophthalmologist if corneal opacity develops.

Treat the birthing parent of the neonate for N. gonorrhoeae infection – for treatment regimens, management of sexual contacts and information on additional testing (including test of cure), see Approach to Neisseria gonorrhoeae infection.

1 Ceftriaxone may be a suitable alternative to cefotaxime in term neonates who are not receiving intravenous calcium solutions (eg parenteral nutrition, compound sodium lactate [Hartmann solution], lactated Ringer solution) and do not have jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia, or impaired bilirubin binding – seek expert advice and see Practical information on using beta lactams: cephalosporins.Return
2 Intramuscular injection of ceftriaxone is painful; consider reconstituting with lidocaine 1% for children older than 1 month.Return
3 Intramuscular injection of cefotaxime is painful; consider reconstituting with lidocaine 0.5% for children older than 1 month.Return
4 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
5 Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return