Neonatal Conjunctivitis


Article Author:
Kartikeya Makker


Article Editor:
Evan Kaufman


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/18/2019 4:52:08 AM

Introduction

Neonatal eye discharge is usually congenital nasolacrimal duct obstruction or conjunctivitis. Ophthalmia neonatorum (neonatal conjunctivitis) presents during the first four weeks of life with eye discharge and hyperemia and is usually an acquired infection during delivery. Incidence in the United States is around 1% to 2%. It is the most common ocular disease in neonates, and most infections are acquired. Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.[1][2][3][4][5][4]

Etiology

The age of the baby is an important clue towards the etiology of neonatal conjunctivitis; however, bacterial infections can occur anytime. The following is a summary of occurrences and causes.[6][7][8][5][8]

  • First 24 hrs of life: Chemical causes like silver nitrate drops or from prophylactic medicines. like erythromycin drops, gentamicin drops.
  • 24 to 48 hrs of life: Bacterial causes are most likely (Neisseria gonorrhoeae is the most common cause, Staphylococcus aureus).
  • 5 to 14 days of life: Chlamydia trachomatis
  • 6 to 14 days of life: Herpes keratoconjunctivitis
  • 5 to 18 days: Pseudomonas aeruginosa 

Epidemiology

The incidence of infectious neonatal conjunctivitis ranges from 1% to 2%.

The epidemiology of neonatal conjunctivitis changed when silver nitrate solution was introduced in the 1800s to prevent gonococcal ophthalmia.Chlamydia is the most common infectious agent that causes ophthalmia neonatorum in the United States, where 2% to 40% of neonatal conjunctivitis cases are caused by Chlamydia.

In contrast, the incidence of gonococcal ophthalmia neonatorum has been reduced dramatically and causes less than 1% of cases of neonatal conjunctivitis.[5]

Pathophysiology

Neonates are at higher risk of conjunctivitis due to many predisposing factors, such as:

  • Decreased tear production
  • Lack of IgA in tears
  • Decreased immune function
  • Absence of lymphoid tissue in conjunctiva
  • Decreased lysozyme activity

Risk factors include premature rupture of membranes, prolonged delivery, prematurity, poor prenatal care, maternal STI, mechanical ventilation, poor hygiene conditions, history of midwife interference, HIV-infected mother.

Neonates at higher risk of congenital lacrimal duct obstruction include those with Down syndrome, Goldenhar Syndrome, clefting syndromes, midline facial anomalies, hemifacial microsomia, and craniosynostosis.[5]

History and Physical

A purulent discharge, edema, and erythema of the lids and hyperemia of the conjunctiva are suggestive of conjunctivitis. Discharge can be purulent in bacterial conjunctivitis and watery in viral etiology. Gonorrhea has profuse purulent discharge, Pseudomonas has greenish discharge, and chlamydia can be watery followed with purulent and bloody discharge.

Laterality, unilateral conjunctivitis most often is seen with S. aureus, P. aeruginosa, Herpes simplex, and adenovirus. Bilateral conjunctivitis is seen with infection caused by N. gonorrhea or by use of ocular prophylaxis. Chlamydia usually develops in one eye but effects the other after 2 to 7 days.

The physical exam should include evaluation for red reflex, ulcerations (corneal and conjunctival), and adenopathy. One should also rule out signs of respiratory and systemic infection.

History of STI in the mother increases the risk of chlamydia and gonorrhea. Neonatal conjunctivitis is frequently diagnosed in neonates born to HIV-infected mothers.[5]

Evaluation

Differential diagnosis includes eye discharge that can be conjunctivitis or congenital lacrimal duct obstruction. Other diagnoses may be ocular foreign body, orbital or preseptal cellulitis, entropion, trichiasis, eye trauma (corneal abrasion following delivery), dacryocystitis, keratitis, subconjunctival hemorrhage (breakage of vessels during delivery), congenital anomalies of nasolacrimal system, corneal epithelial disease, neonatal abstinence and congenital glaucoma

Physical exam should evaluate for periorbital edema and adenopathy. Examine both eyes/eyelids for swelling and edema, check conjunctiva for injection (congestion of blood vessels) and chemosis (conjunctival swelling). Check for ulcerations and the presence of red reflex. A purulent discharge, edema and erythema of the lids, as well as injection of the conjunctiva, are suggestive of bacterial conjunctivitis.

Lab studies include Gram stain and culture to check WBC and bacteria, as well as sensitivity and culture of the bacteria isolated (chocolate agar and Thayer-Martin media for gonorrhea and blood agar for another medium). A Giemsa stain should be done for chlamydial suspicion.

No imaging and other studies are usually needed, but Fluorescein dye disappearance test can be done to rule out nasolacrimal duct obstruction.[5]

Treatment / Management

General factors important in management include the following:

  • Avoid cross contamination by frequent hand washing and wearing gloves
  • Irrigate eye with sterile isotonic saline
  • Systemic treatment is required for staphylococcal, gonococcal, Chlamydia, Pseudomonas and herpetic conjunctivitis
  • Avoid eye patching
  • Consider Pediatric iInfectious disease and/or Pediatric Ophthalmology consult
  • Chemical conjunctivitis usually resolves with 24 to 72 hours and may be helped with lubrication and artificial tears

Gonococcal conjunctivitis: a medical emergency. Because of PCB resistance, third-generation cephalosporins are the first line antibiotics. It can happen even with appropriate prophylaxis infants delivered to mothers with positive maternal gonococcal infection.[9][10][11][12][13][5][13]

  • Ceftriaxone 25-50mg/kg intravenous or intramuscular x 1 dose
  • Alternative is cefotaxime single dose of 100 mg/kg
  • Isolate the infant during the first 24 hours of parenteral antibiotic therapy
  • Test for concomitant HIV and syphilis
  • Evaluate for disseminated disease (arthritis, meningitis, sepsis, anorectal infection)
  • Consider treating for chlamydia due to high rate of concomitant infection
  • Keep a low threshold to evaluate for systemic infection (sepsis, meningitis)
  • Ophthalmology consult since gonococcal conjunctivitis can lead to perforation and blindness
  • Irrigate the eyes with normal saline at frequent (1 to 2 hour) intervals
  • Topical antibiotics are not necessary

Chlamydial conjunctivitis: Recommended prophylaxis does not prevent chlamydial conjunctivitis, and topical treatment is ineffective and unnecessary.

Erythromycin x 14 days or azithromycin 20 mg/kg/day x 3 days is the recommended treatment. However, the American Academy of Pediatrics still recommends erythromycin because other treatments are not well studied.

A second course is usually required since 1 in 5 cases recur after antibiotic therapy. Pyloric stenosis has been seen in infants less than six weeks old treated with erythromycin.

For infants born to mothers with chlamydia exposure, there is no prophylaxis recommended but it is important to educate the family to monitor for infection including pneumonia.

Herpetic conjunctivitis: Administer topical vidarabine or trifluridine five times a day for ten days, evaluate and treat for systemic herpes, ophthalmology consult is indicated. Systemic treatment with acyclovir is also indicated for SEM (skin eye and mucosa) and central nervous system infection. Ophthalmologic evaluation is recommended as retinopathy, cataracts and chorioretinitis can develop

Isolation: Isolation of a patient is recommended for Pseudomonas, herpes, and gonococcal conjunctivitis.

Lacrimal Duct Obstruction: Most clear spontaneously without treatment. If the problem doest not resolve and symptoms persist (usually after 6 to 7 months), the infant should be evaluated by an ophthalmologist.

Enhancing Healthcare Team Outcomes

Neonatal conjunctivitis is not an uncommon problem seen after delivery. When it occurs, the disorder is best managed by a multidisciplinary team that includes a neonatologist, infectious disease consult, ophthalmologist, pediatrician, pharmacist and a nurse practitioner. There are many causes of neonatal conjunctivities. Ophthalmia neonatorum (neonatal conjunctivitis) presents during the first four weeks of life with eye discharge and hyperemia and is usually an acquired infection during delivery. If left untreated it can lead to complications (ulceration and perforation of the cornea, blindness, chlamydia pneumonia). In severe cases, treatment should be initiated  without waiting for culture results. Empirical treatment should be started soon after sending the culture and tapered once final results are back. The outcomes for most neonates with conjunctivitis are good.[14] (Level V)[5]


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Neonatal Conjunctivitis - Questions

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Which ophthalmic preparation is not recommended for prophylaxis against gonorrhea and chlamydia conjunctivitis in newborns?



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Neonatal Conjunctivitis - References

References

Tan AK, Ophthalmia Neonatorum. The New England journal of medicine. 2019 Jan 10;     [PubMed]
Kara M,Kıvanç SA,Olcaysü OO,Akova Budak B,Özmen AT,Kıvanç M,Hörmet Öz HT, The newborn conjunctival flora at the post delivery 24 hours. Journal of current ophthalmology. 2018 Dec;     [PubMed]
Fiorito TM,Noor A,Silletti R,Krilov LR, Neonatal Conjunctivitis Caused by Neisseria cinerea: A Case of Mistaken Identity. Journal of the Pediatric Infectious Diseases Society. 2018 Nov 21;     [PubMed]
Kaštelan S,Anić Jurica S,Orešković S,Župić T,Herman M,Gverović Antunica A,Marković I,Bakija I, A Survey of Current Prophylactic Treatment for Ophthalmia Neonatorum in Croatia and a Review of International Preventive Practices. Medical science monitor : international medical journal of experimental and clinical research. 2018 Nov 10;     [PubMed]
Zikic A,Schünemann H,Wi T,Lincetto O,Broutet N,Santesso N, Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. Journal of the Pediatric Infectious Diseases Society. 2018 Aug 17;     [PubMed]
Singh G,Galvis A,Das S, Case 1: Eye Discharge in a 10-day-old Neonate Born by Cesarean Delivery. Pediatrics in review. 2018 Apr;     [PubMed]
Smolkin T,Roth-Ahronson E,Kranzler M,Geffen Y,Mashiach T,Kugelman A,Makhoul IR, Optimizing Accessibility of a Hand-wash Gel to Infant's Cradle: Effect on Neonatal Conjunctivitis. The Pediatric infectious disease journal. 2019 Jan;     [PubMed]
Gallenga PE,Del Boccio M,Gallenga CE,Neri G,Pennelli A,Toniato E,Lobefalo L,Maritati M,Perri P,Contini C,Del Boccio G, Diagnosis of a neonatal ophthalmic discharge, Ophthalmia neonatorum, in the “molecular age”: investigation for a correct therapy. Journal of biological regulators and homeostatic agents. 2018 Jan-Feb;     [PubMed]
Harding-Esch EM,Kadimpeul J,Sarr B,Sane A,Badji S,Laye M,Sillah A,Burr SE,MacLeod D,Last AR,Holland MJ,Mabey DC,Bailey RL, Population-based prevalence survey of follicular trachoma and trachomatous trichiasis in the Casamance region of Senegal. BMC public health. 2017 Jul 26;     [PubMed]
Fleming-Dutra KE,Nelson JM,Fischer M,Staples JE,Karwowski MP,Mead P,Villanueva J,Renquist CM,Minta AA,Jamieson DJ,Honein MA,Moore CA,Rasmussen SA, Update: Interim Guidelines for Health Care Providers Caring for Infants and Children with Possible Zika Virus Infection--United States, February 2016. MMWR. Morbidity and mortality weekly report. 2016 Feb 26;     [PubMed]
McAnena L,Knowles SJ,Curry A,Cassidy L, Prevalence of gonococcal conjunctivitis in adults and neonates. Eye (London, England). 2015 Jul;     [PubMed]
Mayor MT,Roett MA,Uduhiri KA, Diagnosis and management of gonococcal infections. American family physician. 2012 Nov 15;     [PubMed]
Zuppa AA,D'Andrea V,Catenazzi P,Scorrano A,Romagnoli C, Ophthalmia neonatorum: what kind of prophylaxis? The journal of maternal-fetal     [PubMed]
Jin J, Prevention of Gonococcal Eye Infection in Newborns. JAMA. 2019 Jan 29;     [PubMed]

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