Neonatal conjunctivitis

This page is for neonatal patients; for non-neonatal pediatric see conjunctivitis (peds) and adult patients see conjunctivitis.

Background

• Neonatal conjunctivitis = ophthalmia neonatorum
• First 30 days of life
• Chemical, Gonococcal, Chlamydial, other bacterial, and viral
• Bacterial causes typically are transmitted during vaginal delivery process (vertical transmission)
  • Per USPSTF, Topical erythromycin for the neonate at birth is recommended as prevention for gonococcal conjunctivitis

Types

Chemical

• Historically due to ocular prophylaxis with silver nitrate
• Occurs on 1st day of life, resolves within 48 hrs
• Less common now with erythromycin ointment replacing silver nitrate

Gonococcal

• Presents at 2-7 days of life (peak 3-5)
• Bilateral conjunctival erythema, chemosis, and eyelid edema
• Copious purulent discharge
• Has potential to cause loss of vision due to corneal ulceration
  • If untreated, may lead to meningitis and bacteremia

Chlamydia

• Similar exam to gonoccocal but starts at 7-14 days of age
• Peaks from 1 week to 1 month after birth
• Leading cause of preventable blindness in the world
  • Chlamydia conjunctivitis is more common than gonococcal
• May present with otitis and chlamydial pneumonia with staccato cough

Herpetic

• Peaks at 6-14 days of life
• Presents with inflammation and edema, less likely purulence
• Look for other mucocutaneous vesicular lesions and assess mother for herpes
• May lead to keratitis and disseminated infection
• Vesicles + conjunctivitis = acyclovir + full sepsis w/u, including for disseminated herpes

Streptococcus/S. Aureus

• 5 weeks to 5 yrs

Clinical Features

Gonococcal ophthalmia neonatorum

Chlamydia

• Can range from mild to severe hyperemia with thick mucopurulent discharge

Gonococcal

• May present as typical conjunctivitis or with severe lid edema, cornea ulceration

Differential Diagnosis

Neonatal eye problems

• Nasolacrimal duct obstruction
• Dacrocystitis
• Conjunctivitis
  • Chemical
  • Gonococcal
  • Chlamydia
  • Herpetic
  • Streptococcus/S. Aureus
• Early onset glaucoma
• Uveitis
• Ocular foreign body
• Corneal abrasion
• Ocular trauma
• Ingrown eyelash

Evaluation

• Obtain information about maternal infectious diseases screening during pregnancy
• Gram stain/culture to rule out N. gonorrhea and C. trachomatis
  • Gram stain followed by culture is important for gonorrhea
  • Chlamydia is obligate intracellular, so a direct swab and PCR of scleral or palpebral conjunctivitis is needed
  • If chlamydia is detected, should prompt evaluation for possible gonorrhea co-infection
• If HSV is suspected, send vesicular fluid for PCR +/- viral culture

Management

Prophylaxis

• Erythromycin 0.5% ointment x1 or tetracycline 1% or silver nitrate 1% x1 topical (rarely used because of its potential for causing chemical conjunctivitis), applied at birth.

Chemical

• Watchful waiting

Gonococcal (onset 2-4 days)

• Cefotaxime 100mg/kg IV or IM OR ceftriaxone 25-50mg/kg IV or IM x1 (not to exceed 125mg)
  • Cefotaxime is preferred because it does not displace bilirubin
  • Disseminated disease should be suspected until CSF is negative
  • Treat mother and partners
  • Irrigate eyes with saline (topical antibiotics are insufficient and unnecessary)

Chlamydia (onset 5-10 days)

• Erythromycin ophthalmic ointment plus one of the following
  • Azithromycin 20mg/kg PO once daily x 3 days OR
  • Erythromycin 50mg/kg PO QD in 4 divided doses x 14 days
• Disease manifests 5 days post-birth to 2 weeks (late onset)

Herpetic (onset 6-14 days)

• Acyclovir 20mg/kg IV q8hr x 14-21d
• Topical antiviral
• Do not give steroids
• Full neonatal sepsis evaluation
• Immediate ophtho consult

NB:

• For conjunctivitis starting >2 weeks of age, most likely pathogens include S. aureus, S. epi, E. coli, pseudomonas, and non-typable H. Flu.
• No systemic therapy necessary, treat w/ bacitracin-polymyxin ointment

Disposition

• Gonococcal
  • Admit all infants for evaluation of disseminated disease (BCx, UA/UCx, CSF) and ophthalmology consult given high risk
• Herpetic
  • Admit

See Also

• Conjunctivitis

Eye Algorithms

• Red eye
  • Bilateral red eyes
  • Unilateral red eye
  • Red eye (by symptoms)
  • Red eye (peds)
    • Neonatal conjunctivitis
• Periorbital swelling
• Acute vision loss (noninflamed)
• Acute onset flashers and floaters
• Painful eyes with normal exam
• Neonatal eye problems