Neonatal Conjunctivitis

Background

• Neonatal conjunctivitis, also known as ophthalmia neonatorum, is an acute mucopurulent conjunctivitis occurring mostly with vaginal delivery, or within the first 4 weeks after birth, usually due to chlamydial (most common) or gonococcal infections, but may also be due to viral infections such as adenovirus, herpes simplex (HSV), or chemical causes.
• A maternal infection (including sexually transmitted infections) and a consequent lack of ophthalmia prophylaxis in neonates after birth are the major risk factors for acquiring neonatal conjunctivitis.
• 50% of infants with chlamydial conjunctivitis will have infection of other sites, including the lungs (pneumonia may occur 1-3 months after infection in 10%-20%), nasopharynx, or genital tract.
• Infants with gonococcal ophthalmia may have other infections, including sepsis and associated meningitis, arthritis, rhinitis, vaginitis, or urethritis.
• Chemical conjunctivitis is common after silver nitrate drops (occurs in 50%-60% of neonates exposed) which typically occurs within hours of exposure and lasts 24 to 36 hours.
• The complications of neonatal conjunctivitis can be severe and depend on the causative organism.

Evaluation

• Ophthalmia neonatorum can be diagnosed in any infant with conjunctivitis at ≤ 30 days old.
  • An ocular finding of conjunctivitis (unilateral or bilateral) may include:
    • significant conjunctival erythema and swelling
    • watery discharge
    • mucopurulent
    • eyelid edema
    • pseudomembrane
    • papillary conjunctivitis
    • herpetic vesicles on eyelid margins
  • The onset of symptoms may suggest the underlying cause, including:
    • symptoms within hours of birth following exposure to medication or toxin (especially prophylactic agent silver nitrate) suggests chemical conjunctivitis
    • hyperacute conjunctivitis occurring within 24-48 hours after birth suggests Neisseria gonorrhoeae
    • symptoms 5-14 days after birth suggests either Chlamydia trachomatis, herpes simplex virus (HSV), or other bacterial infections such as complications from lacrimal duct stenosis
    • symptoms of viral conjunctivitis will occur after hospital discharge once the infant has had an opportunity for exposure to viral respiratory pathogens
• Testing for the underlying etiology should include a specimen swab containing epithelial cells from an everted eyelid.
  • Perform a Gram stain, culture, and antibiotic susceptibility testing if the result is positive.
    • Consider N. gonorrhoeae if gram-negative diplococci and white blood cells are present.
    • The diagnosis is confirmed with a positive culture for N. gonorrhoeae.
  • Perform chlamydial culture and nonculture assay tests. The diagnosis is confirmed with a positive culture or assay tests for C. trachomatis.
  • Perform polymerase chain reaction (PCR) on specimen for herpes simplex virus in a neonate with suspected herpetic disease. The diagnosis is confirmed by the presence of herpetic vesicles on eyelid margins or with a positive PCR for herpes simplex virus (HSV).
• If HSV keratitis/conjunctivitis is suspected, comprehensive testing and management for disseminated Neonatal herpes should be initiated.

Management

• Gonococcal ophthalmia neonatorum:
  • For infants presenting with suspected gonococcal conjunctivitis in the first 48 hours of life:
    • hospitalize and monitor for signs of disseminated infection.
    • obtain a lumbar puncture, complete blood count (CBC), and a blood culture prior to administration of parenteral therapy, and then treat with empiric antibiotics.
  • For a confirmed infection, give ceftriaxone 25-50 mg/kg intramuscularly or IV as a single dose, not to exceed 125 mg.
  • Use frequent saline irrigation and consider the addition of topical therapy if copious purulent discharge is present.
• Chlamydial neonatal ophthalmia:
  • For infants presenting with suspected chlamydial neonatal ophthalmia, treat if the diagnosis is confirmed.
  • Use erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days or azithromycin 20 mg/kg orally once daily for 3 days.
  • Topical ophthalmic therapy alone is insufficient and does not add value when added to systemic therapy.
  • Monitor for signs of pyloric stenosis.
  • Give a second course of oral antibiotic if chlamydial conjunctivitis does not improve, since 20% may not respond to the initial course.
• Herpetic ophthalmia neonatorum:
  • For infants presenting with suspected herpetic ophthalmia neonatorum:
    • hospitalize.
    • obtain a lumbar puncture prior to administration of antiviral therapy.
  • Use acyclovir 60 mg/kg IV daily in 3 divided doses for 14 days.
  • Use topical ophthalmic antiviral therapy (such as trifluridine drops 9 times per day).
• Consult an infectious disease specialist and pediatric ophthalmologist for conjunctivitis due to Gonorrhea, Chlamydia, or Herpes.
• Topical treatment is adequate for other more common bacterial causes of ophthalmia neonatorum.
• Treat the mother and her sexual partner(s) if a sexually transmitted infection is identified in the infant.
• Preventive measures:
  • Perform maternal screening for gonorrheal infection at the first prenatal visit if there is an increased risk for infection, with a second screening during the third trimester if there is continued risk or if a new risk factor is acquired.
  • Perform maternal screening for chlamydial infection at the first prenatal visit in all pregnant women ≤ 25 years old and if there is an increased risk for infection. Consider a repeat screening in the second semester in women at high risk for infection.
  • Provide prophylactic ocular topical medication against gonococcal and chlamydial ophthalmia neonatorum for all newborns as soon as possible after vaginal or cesarean delivery (Strong recommendation).