Neonatal gonococcal arthritis after negative prenatal screening and despite conjunctival prophylaxis

Sexually Transmitted Infections in Pregnant Women: Integrating Screening and Treatment into Prenatal Care

Chlamydia, gonorrhea, and syphilis continue to be significant burdens to the health of pregnant women and their children despite easy and effective guidance for screening and treatment. Specific guidelines exist for screening for these infections as well as treatment and follow-up. In this article, we review the epidemiology of chlamydia, gonorrhea, and syphilis. Testing methodology is also reviewed as molecular-based techniques have replaced culture as the current gold standard tests of choice for chlamydia and gonorrhea. The nontreponemal and treponemal serologic diagnostic and screening approach to syphilis has undergone less change. Treatment for gonorrhea includes a one-time dose of parenteral ceftriaxone and oral azithromycin. This treatment regimen not only addresses the possible gonococcal resistance seen in recent years but also treats chlamydia, which may present similarly or co-infect the same patient. Syphilis treatment in both pregnant women and their infected neonates remains with penicillin G formulations. It is crucial to establish close follow-up evaluation for the pregnant woman infected with these sexually transmitted infections to ensure adequate treatment and help prevent perinatal spread of the infection.

Septic arthritis in immunocompetent and immunosuppressed hosts

Septic arthritis has long been considered an orthopedic emergency. Historically, Neisseria gonorrhoeae and Staphylococcus aureus have been the most common causes of septic arthritis worldwide but in the modern era of biological therapy and extensive use of prosthetic joint replacements, the spectrum of microbiological causes of septic arthritis has widened considerably. There are also new approaches to diagnosis but therapy remains a challenge, with a need for careful consideration of a combined medical and surgical approach in most cases.

Extragenital manifestations of Neisseria gonorrhoeae

Neisseria gonorrhoeae is a common cause of genitourinary sexually transmitted infections. N. gonorrhoeae is an obligate human pathogen that has evidence of tissue-specific host interactions and diverse extragenital manifestations of infection both in adult and pediatric populations. The clinical presentation of extragenital gonorrhea, diagnostic methods, treatment and preventive measures are reviewed.

Gonococcal infections in neonates and young children

Gonorrhea has been recognized since antiquity, and more than 60 million new cases occur yearly worldwide. Much has been learned about the molecular pathogenesis of infection by Neisseria gonorrhoeae, but immunity from natural infection does not protect against reinfection with the same strain, and the goal of a protective vaccine remains elusive. Gonococcal ophthalmia neonatorum is the most common manifestation in infants born to mothers with gonococcal genital tract infections. Genital and pharyngeal gonococcal infections in young children almost always are acquired from sexual abuse by an infected adult. Invasive disease can occur at any age but is uncommon. Nonculture diagnostic tests are widely used in adults, but culture is required in children for medicolegal purposes. N. gonorrhoeae strains have developed resistance to many antibiotic classes, and resistance profiles vary among geographic regions and within regions over time. Current guidelines for treatment of gonococcal infections in children in the United States are reviewed.

[Septic arthritis in neonates and infants]

INTRODUCTION

Septic arthritis represents an intra-articular infection caused by pyogenic bacteria. During the earliest childhood it is considered to be a systemic septic condition and demands early diagnosis and prompt surgical treatment.

MATERIAL AND METHODS

This is a retrospective analysis of patients with septic arthritis treated at the Department of Orthopedics of the Pediatric Surgery Clinic in Novi Sad, over a 10-year period. We are also presenting a case of a 12-day-old newborn baby, with clear radiological signs of osteoarthritis of the right knee.

RESULTS

A retrospective study included the period 1991-2000, and showed that 15 patients, aged 10 days--12 months were treated for osteoarthritis. The most common localization was the hip, in 60% of cases. In 11 patients the causative agent was Staphylococcus aureus, while in the 4 remaining patients the bacteriologic finding was negative. One patient died of generalized sepsis.

DISCUSSION

In neonates and infants septic arthritis is characterized by atypical clinical picture, often causing delayed diagnosis. In the initial phases of the disease ultrasonographic findings were of greater use compared to radiological imaging, due to relatively late appearance of radiological signs of disease.

CONCLUSIONS

Due to possible development of serious and irreversible damage, even lethal outcome, septic arthritis requires early diagnosis, prompt administration of antibiotics and early surgical treatment. It is a quite unique area in Pediatric Orthopedics where missed or delayed diagnosis may have serious consequences.

Binding of C4b-binding protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae

We screened 29 strains of Neisseria gonorrhoeae and found 16/21 strains that resisted killing by normal human serum and 0/8 serum sensitive strains that bound the complement regulator, C4b-binding protein (C4bp). Microbial surface-bound C4bp demonstrated cofactor activity. We constructed gonococcal strains with hybrid porin (Por) molecules derived from each of the major serogroups (Por1A and Por1B) of N. gonorrhoeae, and showed that the loop 1 of Por1A is required for C4bp binding. Por1B loops 5 and 7 of serum-resistant gonococci together formed a negatively charged C4bp-binding domain. C4bp-Por1B interactions were ionic in nature (inhibited by high salt or by heparin), whereas the C4bp-Por1A bond was hydrophobic. Only recombinant C4bp mutant molecules containing the NH2-terminal alpha-chain short consensus repeat (SCR1) bound to both Por1A and Por1B gonococci, suggesting that SCR1 contained Por binding sites. C4bp alpha-chain monomers did not bind gonococci, indicating that the polymeric form of C4bp was required for binding. Using fAb fragments against C4bp SCR1, C4bp binding to Por1A and Por1B strains was inhibited in a complement-dependent serum bactericidal assay. This resulted in complete killing of these otherwise fully serum resistant strains in only 10% normal serum, underscoring the importance of C4bp in mediating gonococcal serum resistance.