Neonatal Conjunctivitis

The major causes of neonatal conjunctivitis (in decreasing order) are the following:

• Bacterial infection

• Viral infection

• Chemical inflammation

Infection is acquired from infected mothers by contact with vaginal fluid. Chlamydial ophthalmia (caused by Chlamydia trachomatis) is a common bacterial cause (1). The reported prevalence of maternal chlamydial infection varies by age and location and is estimated to be approximately 8% (2). Data from before routine screening and treatment of pregnant patients suggest that up to 60% of neonates born to infected patients acquire infection, approximately 30% of those develop conjunctivitis, and approximately 15% develop neonatal pneumonia (3). Other bacteria, including Streptococcus pneumoniae, Staphylococcus aureus, and nontypeable Haemophilus influenzae, account for many of the remaining bacterial cases, whereas gonococcal ophthalmia (conjunctivitis due to Neisseria gonorrhoeae) is relatively rare.

The major viral cause is herpes simplex virus types 1 and 2 (herpetic keratoconjunctivitis), but this virus is a relatively rare cause of neonatal conjunctivitis overall.

Chemical conjunctivitis is usually secondary to the instillation of topical therapy for ocular prophylaxis.

Causes of neonatal conjunctivitis are difficult to distinguish clinically because they overlap in both manifestation and onset. Conjunctivae are injected, and discharge (watery or purulent) is present.

Chlamydial ophthalmia usually occurs 5 to 14 days after birth. It may range from mild conjunctivitis with minimal mucopurulent discharge to severe eyelid edema with copious drainage and pseudomembrane formation. Follicles are not present in the conjunctiva, as they are in older children and adults.

Gonococcal ophthalmia causes an acute purulent conjunctivitis that appears 2 to 5 days after birth or earlier with prelabor rupture of membranes. The neonate has severe eyelid edema followed by chemosis and a profuse purulent exudate that may be under pressure. If untreated, corneal ulcerations and blindness may occur.

Ophthalmia Neonatorum

Hide Details

This image shows gonococcal ophthalmia. Symptoms and signs of eyelid edema, chemosis, and purulent discharge develop 2 to 5 days after delivery.

DR M.A. ANSARY/SCIENCE PHOTO LIBRARY

Conjunctivitis caused by other bacteria has a variable onset, ranging from 4 days to several weeks after birth.

Herpetic keratoconjunctivitis can occur as an isolated infection or with disseminated or central nervous system infection. It can be mistaken for bacterial or chemical conjunctivitis, but the presence of dendritic keratitis is pathognomonic.

Chemical conjunctivitis secondary to topical prophylaxis usually appears within 6 to 8 hours after instillation and disappears spontaneously within 48 to 96 hours.

• Testing of conjunctival material for pathogens including gonorrhea, chlamydia, and, sometimes, herpes

Chlamydial and gonococcal infections are best diagnosed with nucleic acid amplification techniques because of their high sensitivity and specificity. However, conjunctival material can be Gram stained, cultured for gonorrhea (eg, on modified Thayer-Martin medium) and other bacteria, and tested for chlamydia (eg, by culture, direct immunofluorescence, or enzyme-linked immunosorbent assay [samples must contain cells]). Conjunctival scrapings can also be examined with Giemsa stain; if blue intracytoplasmic inclusions are identified, chlamydial ophthalmia is confirmed.

Viral testing is performed only if viral infection is suspected because of skin lesions or maternal infection.

• Systemic, topical, or combined antimicrobial therapy

In chlamydial ophthalmia, systemic therapy is the treatment of choice because at least half of affected neonates also have nasopharyngeal infection and some will develop chlamydial pneumonia. Erythromycin ethylsuccinate or azithromycin is recommended; however, data on treatment with systemic therapy is the treatment of choice because at least half of affected neonates also have nasopharyngeal infection and some will develop chlamydial pneumonia. Erythromycin ethylsuccinate or azithromycin is recommended; however, data on treatment withazithromycin are limited. Efficacy of erythromycin treatment is only 80% (1), so a second treatment course may be needed. Because use of erythromycin in neonates is associated with the development of hypertrophic pyloric stenosis (HPS), all neonates treated with this medication should be monitored for symptoms and signs of HPS, and their parents should be counseled regarding the potential risks.

Neonates with conjunctivitis and known maternal gonococcal infection or with gram-negative intracellular diplococci identified in conjunctival exudates should be hospitalized, evaluated for disseminated infection, and treated with ceftriaxone or cefotaxime before results of confirmatory tests are available. Infants with or with gram-negative intracellular diplococci identified in conjunctival exudates should be hospitalized, evaluated for disseminated infection, and treated with ceftriaxone or cefotaxime before results of confirmatory tests are available. Infants withhyperbilirubinemia or those receiving calcium-containing fluids should not receive ceftriaxone but may be given a single dose of cefotaxime. Frequent saline irrigation of the eye prevents secretions from adhering. Topical antimicrobial ointments alone are ineffective and not needed when systemic therapy is provided.

Conjunctivitis due to other bacteria usually responds to topical ointments containing polymyxin/bacitracin, erythromycin, or tetracycline.Conjunctivitis due to other bacteria usually responds to topical ointments containing polymyxin/bacitracin, erythromycin, or tetracycline.

Herpetic keratoconjunctivitis should be treated with systemic acyclovir and topical 1% trifluridine or 0.15% ganciclovir and in consultation with an ophthalmologist. Systemic therapy is important because dissemination to the central nervous system and other organs can occur.Herpetic keratoconjunctivitis should be treated with systemic acyclovir and topical 1% trifluridine or 0.15% ganciclovir and in consultation with an ophthalmologist. Systemic therapy is important because dissemination to the central nervous system and other organs can occur.

Corticosteroid-containing ointments may seriously exacerbate eye infections due to C. trachomatis and herpes simplex virus and should be avoided.

Routine use of silver nitrate drops, erythromycin ointment, or tetracycline ophthalmic ointment or drops instilled into each eye at birth effectively prevents gonococcal ophthalmia. However, none of these agents prevents chlamydial ophthalmia; povidone iodine drops may be effective against chlamydia and gonococci (not available in the United States). Silver nitrate and tetracycline ophthalmic ointments also are not available in the United States.Routine use of silver nitrate drops, erythromycin ointment, or tetracycline ophthalmic ointment or drops instilled into each eye at birth effectively prevents gonococcal ophthalmia. However, none of these agents prevents chlamydial ophthalmia; povidone iodine drops may be effective against chlamydia and gonococci (not available in the United States). Silver nitrate and tetracycline ophthalmic ointments also are not available in the United States.

Screening and treating pregnant patients for gonorrhea and chlamydia are the most effective ways to prevent neonatal chlamydial infection, including conjunctivitis and pneumonia. Neonates of mothers with untreated gonorrhea should receive a single injection of ceftriaxone. Specifically, all pregnant patients who are < 25 years old or who are ≥ 25 years old with ≥ 1 risk factors (eg, history of prior STI, engagement in high-risk sexual behavior, partner has an STI or engages in high-risk behavior, history of incarceration) are screened at the first prenatal visit and again during the third trimester if risk remains high (Screening and treating pregnant patients for gonorrhea and chlamydia are the most effective ways to prevent neonatal chlamydial infection, including conjunctivitis and pneumonia. Neonates of mothers with untreated gonorrhea should receive a single injection of ceftriaxone. Specifically, all pregnant patients who are < 25 years old or who are ≥ 25 years old with ≥ 1 risk factors (eg, history of prior STI, engagement in high-risk sexual behavior, partner has an STI or engages in high-risk behavior, history of incarceration) are screened at the first prenatal visit and again during the third trimester if risk remains high (1, 2, 3).

To prevent neonatal herpes infection, pregnant patients with a history of genital herpes should be offered suppressive viral therapy at or beyond 36 weeks gestation (4). Cesarean delivery is recommended for pregnant patients with active genital herpes simplex lesions or prodromal symptoms at the time of delivery.