Guidelines for the control of gonococcal conjunctivitis in the Northern Territory

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Northern Territory Department of Health Library Services Historical Collection

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Guidelines for the Control of

Gonococcal Conjunctivitis in the

Northern Territory

January 2003

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ABORIGINAL HEALTH COLLECTION

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Centre for Disease Control

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Casuarina NT 0811

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CONTENTS

Background

1

Case Definition

1

Clinical features 1

Case definition 1

Clinical Picture

1

Mode of transmission

2

Incubation

2

Period of communicability

2

Diagnosis

2

Management of Cases

2

Treatment

3

Standard 3

Alternative 4

Management of Contacts

4

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Guidelines for the control of gonococcal coniunctivitis in the Northern Territory

Gonococcal conjunctivitis is a highly contagious eye infection caused by Neisseria gonorrhoeae. It is a notifiable disease. Cases are rarely seen in isolation in the Northern Territory (NT) and follow up and treatment of contacts is essential.

Clinical features

A clinical illness characterised by intense inflammation of the conjunctivae, copious purulent discharge with or without periorbital oedema.

Case definition

Neisseria gonorrhoeae detected:

On culture of a conjunctiva! specimen.

OR By a molecular technique such as PCR#.

OR Clinically compatible illness and either:

• gram negative intracellular diplococci visible on microscopy of a conjunctiva! specimen OR

• epidemiologically linked to a laboratory confirmed case. This includes any other proven case in a remote Aboriginal community.

# Polymerase Chain Reaction

Gonococcal conjunctivitis is usually a localised infection of the conjunctivae, however corneal ulceration, perforation and blindness can occur if treatment is not given promptly. More disseminated infection including gonococcal arthritis has been reported in the NT.

Neonatal infection ( ophthalmia neonatorum) is a potentially more serious clinical picture than gonococcal infection seen in older children and adults, and the mode of transmission is different, which means that management is different.

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Guidelines for the control of gonococcal coniunctivitis in the Northern Territory

·. Mode, of Transmission'.·

In children and adults transmission is either direct from person to person from contaminated fingers, or indirect transmission from contaminated fomites, or from flies. Heavy rains and an increase in fly numbers may precipitate an outbreak.

Neonatal infection occurs during passage of the infant through the birth canal where the mother is infected with genital Neisseria gonorrhoeae.

With isolated cases or a household cluster, the source may be someone with a genital infection .

. '' h,cubation : .," ,,,

Usually 2 to 7 days, but sometimes can be longer.

. · <i. Period of Ce>mrn~nicability _ .. ·· ·

May extend for months in untreated people. Infectivity ceases within hours of appropriate antibiotic therapy. Patients should be isolated / excluded from school until 24 hours after treatment.

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Swabs should be taken from all suspect patients with a discharging eye for microscopy, culture and sensitivity (MC&S) and PCR.

• Moisten the swab with sterile normal saline and swab the eye.

• Roll the swab on a slide and let the slide air dry.

• Place the swab in Modified Amies or Stuart's transport medium.

• Do not refrigerate.

• If there is a delay in receiving the specimen in the laboratory, culture may fail to grow Neisseria gonorrhoeae, however gram negative intracellular diplococci will be visible on microscopy, and is considered to be diagnostic and may be supported by positive PCR.

Managimento,cases

• Collect a swab as above.

• Irrigate the eyes with saline solution to remove the discharge.

• If eye is very crusted it may be necessary to bathe the eyes to remove the crusting. If so, use sterile cotton wool balls well moistened with normal saline. Wipe from inner canthus outwards.

Use a fresh ball for each wipe and dispose of in a biohazard bag.

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Guidelines for the control of gonococcal coniunctivitis in the Northern Territory

• If possible check visual acuity, and check cornea for ulceration. If abnormal refer to local doctor for management.

• Treat with single dose antibiotics (see below).

• Encourage frequent washing of face and hands with warm water and soap.

• Provide information to all close household contacts and family members on the importance of good hygiene as a way of preventing the spread of infection.

• Warn families to re-present if there is persisting eye infection, fevers or other symptoms such as arthritis.

• Exclude from school or child care for 24 hours after treatment.

• Report to the Centre for Disease Control (CDC) by phone/fax or e-mail as soon as possible.

• Treat contacts (see below).

• If case is in a neonate admit urgently to hospital.

• If a neonatal infection, do a full STD screen on the mother and then treat.

• Pharyngeal swabs are not routinely taken unless the patient is symptomatic with a sore throat.

• To exclude genital infection, self administered low vaginal swab, T-Test#, or endo-cervical swab in women or urine test (first void of 10 to 30mls, not mid stream urine), in men, for gonorrhoea and chlamydia may be indicated.

# Tampon test is a patient inserted vaginal tampon submitted for testing and is only available at private pathology services.

Treatment

Standard

Neonates: < l month (ophthalmia neonatorum)

~ ADMIT TO HOSPITAL URGENTLY for intravenous antibiotics.

Children and adults:

~ Procaine penicillin intramuscularly (IM) as a single dose

50,000 units = 50 mg /kg (to a maximum of 1,500,000 units = 1.5g)

Usin Procaine Penicillin 1 500 000 units

=

1.5 3.4ml

Wei ht m amount

3k 250m 0.6 ml

6k 375m 0.8 ml

10k 500m 1.1 ml

15 k 750m 1.7 ml

20k 1.0 2.3 ml

-Greater than 30 k 1.5 3.4 ml

Adapted from CARP A Standard Treatment Manual ¹

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Guidelines for the control of gonococcal coniunctivitis in the Northern Territory

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From CARPA Standard Treatment Manual¹ Alternative

For cases with hypersensitivity to penicillin ( excluding immediate hypersensitivity, i.e. anaphylactic reaction) or where the standard treatment has failed, or if infection is known to be due to penicillinase producing Neisseria gonorrhoeae (PPNG) alternative treatment should be used. Failed treatment is defined as no substantial decrease in discharge, conjunctival injection or peri-orbital oedema within 24 hours of treatment.

In an outbreak situation, pharyngeal swabs are not routinely recommended unless the patient is symptomatic. Where a pharyngeal swab has been taken and is positive, alternative treatment should · be given.

The alternative treatment for standard treatment failure, PPNG, and delayed hypersensitivity (which excludes immediate hypersensitivity reaction and anaphylaxis) is:

Intramuscular ceftriaxone dissolved in 1 % lignocaine hydrochloride, as a single intramuscular dose.

==> Weight s 25 kg:

=::> Weight > 25 kg:

125 mg 250mg

For those with immediate hypersensitivity, i.e. anaphylactic reaction, seek specialist medical advice.

Note: Infants below 6 weeks of age should not be given ceftriaxone. Refer to hospital.

· .:,::- Management ofContacts , : <

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• Treat all household contacts of a case with a single does of the standard treatment of procaine penicillin or amoxycillin with probenecid ( or alternative treatment as above, if allergic to penicillinf

• For those with symptoms/signs follow the steps taken for management of cases.

• If the case attends child care or school, then those in the same classroom need treatment.

• Encourage good personal hygiene and regular washing of face and hands with water and soap.

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I

Guidelines for the control of gonococcal coniunctivitis in the Northern Territory

Reference

1. Central Australian Rural Practitioners Association Alice Springs, CARPA Standard Treatment Manual, ^3rd ed. Central Australian Rural Practitioners Association Alice Springs, 1997.

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CDC 2003

For further information contact

Centre for Disease Control (CDC), Darwin Ph: 8922 8044 Fax: 8922 8310

OR

Your regional CDC

Nhulunbuy Ph: 8987 0359 Katherine Ph: 8973 9049 Alice Springs Ph: 8951 7550 Tennant Creek Ph: 8962 4259