Transmission of Neisseria gonorrhoeae to the newborn infant can occur in utero, during delivery, or after birth. In utero acquisition occurs via an ascending route after rupture of amniotic membranes. More commonly, neonatal infection occurs at delivery from passage through an infected birth canal. Approximately 30% of infants born vaginally to infected mothers become colonized with N. gonorrhoeae. Horizontal transmission via fomites, by nursery personnel, and household contacts also is documented. Standard precautions are recommended for hospitalized infants with gonococcal infection. The incubation period is usually 2 to 7 days.

Conjunctivitis is the most frequently observed clinical manifestation of gonococcal infection in newborns. Although Chlamydia trachomatis is the most common cause of ophthalmia neonatorum, identification and treatment of N. gonorrhoeae is especially important because it can cause severe eye damage. Gonococcal conjunctivitis typically appears 2 to 5 days after
birth and produces an acute, purulent, bilateral conjunctivitis with lid edema and chemosis. If treatment is delayed, the cornea may ulcerate and scar, resulting in loss of visual acuity. Ultimately, the eye may perforate, resulting in panophthalmitis and loss of the eye. Presumptive diagnosis of gonococcal conjunctivitis may be made by Gram stain of the conjunctival exudate, which demonstrates gram-negative intracellular diplococci. The diagnosis must be confirmed by isolation of the organism on selective media, especially because Moraxella catarrhalis and N. meningitidis have a similar appearance on Gram stain. Other bacterial pathogens associated with conjunctivitis in the neonate that may be visualized on Gram stain are Haemophilus species, Staphylococcus aureus, enterococcus, and Streptococcus pneumoniae. Pseudomonas aeruginosa may cause conjunctivitis with severe complications in debilitated neonates.