Neonatal conjunctivitis

Neonatal conjunctivitis
A newborn with gonococcal ophthalmia neonatorum
Classification and external resources
Specialty	pediatrics
ICD-10	A54.3, P39.1
ICD-9-CM	098.40, 771.6
DiseasesDB	9237
MedlinePlus	001606
eMedicine	oph/325
MeSH	D009878

Neonatal conjunctivitis, also known as ophthalmia neonatorum, is a form of conjunctivitis and a type of neonatal infection contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrhoeae or Chlamydia trachomatis. Antibiotic ointment is typically applied to the newborn's eyes within 1 hour of birth as prevention against gonococcal ophthalmia.^[1] Most hospitals in the United States are required by state law to apply eye drops or ointment soon after birth to prevent the disease.^[2] If left untreated it can cause blindness.

Signs and symptoms

Neonatal conjunctivitis by definition presents during the first month of life. It may be infectious or non infectious.^[3] In infectious conjunctivitis, the organism is transmitted from the genital tract of an infected mother during birth or by infected hands.

• Pain and tenderness in the eyeball.
• Conjunctival discharge: purulent, mucoid or mucopurulent depending on the cause.
• Conjunctiva shows hyperaemia and chemosis. Eyelids are usually swollen.
• Corneal involvement (rare) may occur in herpes simplex ophthalmia neonatorum.

Time of onset

Chemical causes: Right after delivery

Neisseria gonorrhoeae: Delivery of the baby until 5 days post-birth (Early onset).

Chlamydia trachomatis: 5 days post-birth to 2 weeks (Late onset—C.trachomatis has longer incubation period)

Complications

Untreated cases may develop corneal ulceration, which may perforate resulting in corneal opacification and Staphyloma formation.

Cause

Non infectious

Chemical irritants such as silver nitrate can cause chemical conjunctivitis, usually lasting 2–4 days. Thus, prophylaxis with a 1% silver nitrate solution is no longer in common use.^[4] In most countries neomycin and chloramphenicol eye drops are used instead. However, it is possible for newborns to suffer from neonatal conjunctivitis due to reactions with chemicals in these common eye drops.^[5] Additionally, a blocked tear duct may be another non-infectious cause of neonatal conjunctivitis.

Infectious

Many different bacteria and viruses can cause conjunctivitis in the neonate. The two most common causes are N. gonorrheae and Chlamydia acquired from the birth canal during delivery.

Ophthalmia neonatorum due to gonococci (Neisseria gonorrhoeae) typically manifests in the first five days post birth and is associated with marked bilateral purulent discharge and local inflammation. In contrast, conjunctivitis secondary to infection with chlamydia (Chlamydia trachomatis) produces conjunctivitis after day three post birth, but may occur up to two weeks after delivery. The discharge is usually more watery in nature (mucopurulent) and less inflamed. Babies infected with chlamydia may develop pneumonitis (chest infection) at a later stage (range 2 weeks – 19 weeks after delivery). Infants with chlamydia pneumonitis should be treated with oral erythromycin for 10–14 days.^[6]

Other agents causing ophthalmia neonatorum include Herpes simplex virus (HSV 2), Staphylococcus aureus, Streptococcus haemolyticus, Streptococcus pneumoniae.

Prevention

Antibiotic ointment is typically applied to the newborn's eyes within 1 hour of birth as prevention against gonococcal ophthalmia.^[1] This maybe erythromycin, tetracycline, or silver nitrate.^[1]

Treatment

Prophylaxis needs antenatal, natal, and post-natal care.

• Antenatal measures include thorough care of mother and treatment of genital infections when suspected.
• Natal measures are of utmost importance as mostly infection occurs during childbirth. Deliveries should be conducted under hygienic conditions taking all aseptic measures. The newborn baby's closed lids should be thoroughly cleansed and dried.
• If it is determined that the cause is due to a blocked tear duct, a gentle palpation between the eye and the nasal cavity may be used to clear the tear duct. If the tear duct is not cleared by the time the newborn is one year old, surgery may be required.^[2]
• Postnatal measures include:

• Use of 1% tetracycline ointment or 0.5% erythromycin ointment or 1% silver nitrate solution (Crede's method) into the eyes of babies immediately after birth
• Single injection of ceftriaxone IM or IV should be given to infants born to mothers with untreated gonococcal infection.
• Curative treatment as a rule, conjunctival cytology samples and culture sensitivity swabs should be taken before starting treatment

• Chemical ophthalmia neonatorum is a self-limiting condition and does not require any treatment.
• Gonococcal ophthalmia neonatorum needs prompt treatment to prevent complications. Topical therapy should include

• Saline lavage hourly till the discharge is eliminated
• Bacitracin eye ointment four times per day (Because of resistant strains topical penicillin therapy is not reliable. However in cases with proved penicillin susceptibility, penicillin drops 5000 to 10000 units per ml should be instilled every minute for half an hour, every five minutes for next half an hour and then half-hourly till infection is controlled)
• If the cornea is involved then atropine sulphate ointment should be applied.
• The advice of both the pediatrician and ophthalmologist should be sought for proper management.

Systemic therapy: Newborns with gonococcal ophthalmia neonatorum should be treated for seven days with one of the following regimens ceftriaxone, cefotaxime, ciprofloxacin, crystalline benzyl penicillin

• Other bacterial ophthalmia neonatorum should be treated by broad spectrum antibiotics drops and ointment for two weeks.
• Neonatal inclusion conjunctivitis caused by Chlamydia trachomatis responds well to topical tetracycline 1% or erythromycin 0.5% eye ointment QID for three weeks. However systemic erythromycin should also be given since the presence of chlamydia agents in conjunctiva implies colonization of upper respiratory tract as well. Both parents should also be treated with systemic erythromycin.
• Herpes simplex conjunctivitis should be treated with intravenous acyclovir for a minimum of 14 days to prevent systemic infection.^[7]

Epidemiology

The disease incidence varies widely depending on the geographical location. The most extensive epidemiological survey on this subject has been carried out by Dharmasena et al.^[8] who analysed the number of neonates who developed neonatal conjunctivitis in England from 2000 to 2011. In addition to the incidence of this sight threatening infection they also investigated the time trends of the disease. According to them the incidence of Neonatal conjunctivitis (Ophthalmia Neonatorum) in England was 257 (95% confidence interval: 245 to 269) per 100,000 in 2011.

Research

An upcoming meta-analysis will seek to determine if any type of ophthalmia neonatorum prophylaxis reduces the incidence of conjuncitivitis in neonates and to determine which ophthalmia neonatorum prophylaxis is most effective at reducing the incidence of conjunctivitis in neonates.^[9] Eight comparisons to be made in the review include:

1. Any versus no prophylaxis
2. Erythromycin versus no prophylaxis
3. Povidone-iodine versus no prophylaxis
4. Tetracycline versus no prophylaxis
5. Erythromycin verus Tetracycline
6. Povidone-iodine versus Erythromycin
7. Povidone-iodine versus Tetracycline
8. Povidone-iodine versus Chloramphenicol

References

See also

• List of systemic diseases with ocular manifestations