Neonatal Conjunctivitis

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Neonatal Conjunctivitis
Classification and external resources
Neonatal Conjunctivitis

Neonatal Conjunctivitis

ICD-9 771.6


Neonatal conjunctivitis is defined as conjunctival inflammation occurring within the first 30 days of life. Numerous etiologies have been implicated including chemical conjunctivitis as well as viral and bacterial infections. Complications range from mild hyperemia and scant discharge to permanent scarring and blindness.

Disease Entity

Neonatal Conjunctivitis. Also known as neonatorum ophthalmia. ICD-9 771.6

Disease

Neonatal conjunctivitis is defined as conjunctival inflammation occurring within the first 30 days of life. Numerous etiologies have been implicated including chemical conjunctivitis as well as viral and bacterial infections. Complications range from mild hyperemia and scant discharge to permanent scarring and blindness.

Prevalence

Prevalence of neonatal conjunctivitis has decreased significantly in developed countries since the abandonment of silver nitrate as topical prophylaxis. Current estimates of prevalence of neonatal conjunctivitis in developed countries are typically < 0.5%. However, a higher incidence of neonatal conjunctivitis is still found certain regions of the world, particularly in developing countries. A recent study found an estimated prevalence of 17% among nearly 1000 newborn infants in Pakistan.[1]Indicidence of neonatal conjunctivitis remains high in Africa.[2]

Etiology

The three main etiologies of neonatal conjunctivitis include:

  • Chemical
  • Bacterial (C. trachomatis most common)
  • Viral

Chemical

  • Classically, the most common cause of neonatal conjunctivitis due to use of post-delivery use of ophthalmic silver nitrate used in the prophylaxis of ocular gonococcal infections
  • However, the incidence of chemical conjunctivitis in the United States has significantly decreased since replacement of silver nitrate with erythromycin ointment

Bacterial

Bacterial cause of neonatal conjunctivitis include:

  • Chlamydia trachomatis (most common)
  • Neisseria gonnorhea
  • S. aureus
  • Pseudomonas aeruginosa *
  • Streptococcus spp. (including S.haemolyticus, S. pneumonia)
  • Other bacteria include Klebsiella, Proteus, Enterobacter, Serratia, and Eikenella corrodens[3]

Viral

Viral etiologies include:

  • Herpes simplex virus (HSV)


N. gonorrhea is one of the most severe and feared causes of neonatal conjunctivitis, requiring prompt diagnosis and treatment.

  • Pseudomonas, although rare, may lead to potentially blinding complications such as rapid corneal ulceration and perforation.

Risk Factors

Risk factors of neonatal conjunctivitis may include:

  • Maternal infections harbored in the mother's birth canal
  • HIV-infected mothers[4]
  • Exposure of the infant to infectious organisms
  • Increased birth weight[4]
  • Inadequacy of ocular prophylaxis immediately after birth
  • PROM[5]
  • Ocular trauma during delivery
  • Mechanical ventilation
  • Prematurity
  • Poor prenatal care
  • Poor hygienic delivery conditions
  • Post-delivery infection due to direct contact with health care workers or by aerosolization
  • Silver nitrate exposure

Pathophysiology

  • Inflammation of conjunctiva causing erythema, blood vessel dilation, tearing, and drainage
  • This reaction tends to be more serious due to the following: reduced tear secretion, decreased immune function, decreased lysozyme activity and relative absence of lymphoid tissue of the conjunctiva
  • Neonate tears also lack immunoglobulin IgA


Prevention

Prevention through good prenatal care and treatment of chlamydial, gonococcal, or herpetic infections during pregnancy remains the best preventative method

  • Chlamydial infections occur in 4–10% of pregnant women in the United States
  • Infants whose mothers have untreated chlamydial infections have a 30–40% chance of developing conjunctivitis (incidence of 6.2 per 1000 live births)

Topical Prophylaxis

Use of topical silver nitrate to prevent neonatal gonococcal conjunctivitis was first introduced by Credé in 1880 and has been classically been cited as the most common cause of neonatal conjunctivitis. However, the incidence of chemical conjunctivitis has declined as the use of silver nitrate as prophylaxis has been abandoned in many modern countries in favor of topical medications with a more favorable side effect profile such as erythromycin. Topical 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection.[6] 2.5% povidone-iodine solution may also may be useful in preventing neonatal ophthalmia and currently used in Europe although not currently approved for such in the U.S. Recent studies showed that significantly fewer chlamydial infections occurred with povidone-iodine than with silver nitrate or erythromycin (5.5 versus 10.5 and 7.4 percent, respectively). Silver nitrate appears to be the best agent in areas where the incidence of penicillinase-producing N gonorrhoeae (PPNG) is significant. Neomycin and chlorimphenicol are additional topical prophylactic options.

Recent shortage of ophthalmic erythromycin ointment in the United States has lead to rationing and search for efficacious and cost-effective alternatives such azithromycin.[7]

Systemic Prophylaxis

Infants with possible infectious exposure in utero or during birth process should receive appropriate prophylaxis following birth in attempt to prevent ocular and systemic complications. Gonoccal prophylaxis includes single injection of ceftriaxone 50 mg/kg IM or IV in those neonates born to mothers with untreated or suspected gonococcal infection.

  • Other preventative measures include proper hand-washing techniques by peripartum and nursery staff.

Diagnosis

Prompt diagnosis is key in establishing proper treatment and minimizing potential serious complications of neonatorum ophthalmia.

History

Time frame of signs/symptoms following birth play an important role in determining the most likely etiology and subsequent proper diagnosis and treatment:

  • Chemical conjunctivitis (Typically presents within first 24 hours following birth)
  • Neisseria gonorrhea (3-5 days after birth)
  • C. trachomatis (5-14 days)
  • HSV (1-2 weeks)

Physical examination

A thorough examination of the globe and periocular structures of a neonate suspected to have neonatal conjunctivitis is crucial. Corneal involvement should be investigated closely with and without fluorescein and blue cobalt light.  A complete systemic examination should be performed by trained physician familiar with the physical exam of a neonate.

Signs/Symptoms

Non-specific signs of neonatal conjunctivitis include conjunctival injection, tearing, mucopurulent or non-purulent discharge, chemosis, and eyelid swelling.

Signs of specific etiologies include:

Chemical

  • Typically results in mild conjunctival injection accompanied by tearing, spontaneously resolving within 2-4 days

Chlamydia trachomatis

  • Presentation may range from mild hyperemia with scant mucoid discharge to eyelid swelling, chemosis, and pseudomembrane formatiom

Neisseria gonorrhea

  • Typically, patient presents with acute conjunctivitis, associated with chemosis, severe lid edema, and mucopurulent discharge
  • Corneal involvement is the most serious complication, involving diffuse epithelial edema and ulceration that may progress to perforation of the cornea and endophthalmitis
  • Initially, superficial keratitis gives the corneal surface a lackluster appearance followed by marginal and central infiltrates appear, which then ulcerate, sometimes forming a ring abscess

HSV

  • Typically present with unilateral or bilateral lid edema, moderate amount of conjunctival injection, and nonpurulent, serosanguineous discharge
  • Other signs include vesicles on the skin surrounding the eye and corneal epithelial involvement with microdendrites or geographic ulcers, being are the most typical signs of herpetic keratitis in newborns (in contrast to typical dendrites as seen in adults)
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Differential Diagnosis

The differential diagnosis of neonatal conjunctivitis includes:

  • Dacrocysitis
  • Congenital glaucoma
  • Nasolacrimal duct obstruction
  • Preseptal/Orbital cellulitis
  • Congenital glaucoma
  • Infectious keratitis

Laboratory tests

Laboratory studies for suspected infectious etiology should include the following:

  • Conjunctival scraping w/ Gram stain and Giemsa stain for chlamydia
  • Culture on chocolate agar for N gonorrhoeae. (Thayer-Martin media may also be used)
  • Culture on blood agar for other strains of bacteria
  • Culture for HSV if vesicles present or is supicious of viral etiology including evidence of perinatal maternal exposure
  • Direct antibody testing or PCR may also be indicated.[8]
  • Note: Conjunctival specimens for chlamydia testing must include conjunctival epithelial cells because C. trachomatis is an obligate intracellular organism and exudates are not adequate for testing.
  • Cultures may need to be repeated if symptoms worsen or recur following treatment.

Treatment

Chemical conjunctivitis

No treatment required; supportive care only (may use artificial tears q.i.d.)

Typically disappears spontaneously within 2-4 days.

Chlamydial conjunctivitis

Erythromycin drops q.i.d. plus erythromycin elixir 50 mg/kg/day for 2 to 3 weeks While outpatient treatment is an option, hospitalization may be required. Oral erythromycin syrup 50mg/kg/day in four divided doses. Evaluation of systemic involvement needed.

Gonococcal conjunctivitis

Topical irrigation with normal saline to remove mucopurulent discharge. Ceftriaxone in a single dose (25-50 mg/kg IM or IV, up to a maximum of 125 mg). If there is systemic disease, treatment is required for 7 to 14 days depending on the nature of the invasive infection. Bacitracin or erythromycin ointment every 2 to 4 hours. Hospitalization and evaluation for disseminated N. gonorrhea infection. Topical saline drops to remove discharge. Topical atropine if corneal involvement.

  • Note: All neonates with gonococcal conjunctivitis should also be treated for chalmydia. Mother and sexual partner should be treated as well.

HSV keratoconjunctivitis

Acyclovir IV 45mg/kg/day plus vidarabine 3% ointment 5x/day for 14-21 days depending on presence or absence of CNS involvement.

Other bacteria:

  • Gram(+) -Bacitracin ointment q.i.d. for 2 weeks
  • Gram(-) -Gentamicin, tobramycin or ciprofloxacin q.i.d. for 2 weeks

Medical follow up

  • Patients with neonatal conjunctivitis should be followed daily for signs of improvement or worsening, especially acutely due to concerns of rapidly progressing infectious complications such as those mentioned above.
  • Patient should be followed closely by pediatrician for evaluation and treatment of potential systemic infection.

Complications

Ocular complications of neonatal conjunctivitis include pseudomembrane formation, corneal edema, thickened palpebral conjunctivia, peripheral pannus formation, corneal opacification, staphyloma, corneal perforation, endophthalmitis, loss of eye, and blindness.

Systemic complications of chlamydia conjunctivitis include pneumonitis, otitis, and pharyngeal and rectal colonization. Pneumonia has been reported in 10-20% of infants with chlamydial conjunctivitis. Complications of gonococcal conjunctivitis and subsquent systemic involvement include arthritis, meningitis, anorectal infection, septicemia, and death.

Risk of complications can minimized with prompt diagnosis and appropriate antibiotic therapy.

Prognosis

Prognosis of neonatal conjunctivitis is generally considered to be good as long as early diagnosis is made and prompt medical therapy is initiated. Most cases of infectious conjunctivitis respond to appropriate treatment. However, morbidity and mortality increases in cases of systemic involvement requiring hospitalization and intensive monitoring.

Additional Resources

References

  1. Gul SS, Jamal M, Khan N. Ophthalmia neonatorum. J Coll Physicians Surg Pak. 2010 Sep;20(9):595-8.
  2. Isenberg SJ et al. A double application approach to ophthalmia neonatorum prophylaxis. Br J Ophthalmol. 2003 Dec;87(12):1449-52.
  3. Chhabra MS, Motley WW 3rd, Mortensen JE. Eikenella corrodens as a causative agent for neonatal conjunctivitis.J AAPOS. 2008 Oct;12(5):524-5.
  4. 4.0 4.1 Gichuhi S et al. Risk factors for neonatal conjunctivitis in babies of HIV-1 infected mothers. Ophthalmic Epidemiol. 2009 Nov-Dec;16(6):337-45.
  5. Wu J et al. Influence of premature rupture of membranes on neonatal health. Zhonghua Er Ke Za Zhi. 2009 Jun;47(6):452-6.
  6. Darling EK, McDonald H. A meta-analysis of the efficacy of ocular prophylactic agents used for the prevention of gonococcal and chlamydial ophthalmia neonatorum. J Midwifery Womens Health. 2010 Jul;55(4):319-27. Review. 
  7. Keenan JD, Eckert S, Rutar T. Cost analysis of povidone-iodine for ophthalmia neonatorum prophylaxis. Arch Ophthalmol. 2010 Jan;128(1):136-7.
  8. Yip PP et al. The use of polymerase chain reaction assay versus conventional methods in detecting neonatal chlamydial conjunctivitis. J Pediatr Ophthalmol Strabismus. 2008 Jul-Aug;45(4):234-9.
  1. Chen CJ, Starr CE. Epidemiology of gram-negative conjunctivitis in neonatal intensive care unit patients. Am J Ophthalmol. 2008 Jun;145(6):966-970. Epub 2008 Apr 18.
  2. Ophthalmia neonatoum. BCSC series: Pediatric Ophthalmology and Strabismus. American Academy of Ophthalmology; 2010.
  3. Conjunctivitis, Neonatal: eMedicine Ophthalmology. 2009. http://emedicine.medscape.com/article/1192190-overview
  4. Ophthalmia neonatorum (Newborn conjunctivitis). Wills Eye Manual. Philiadelphia.PA: Lippincott Williams & Wilkins; 2008: 181-183.
  5. Ophthalmia neonatorum. Yanoff & Duker: Ophthalmology, 3rd edition. Mosby; 2008: Online.