Neonatal conjunctivitis

Background

• Vesicles + conjunctivitis = full sepsis eval + acyclovir

Clinical Features

Chlamydia

• Can range from mild to severe hyperemia w/ thick mucopurulent discharge

Gonococcal

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

Differential Diagnosis

Chemical

• Due to ocular prophylaxis
• Occurs on 1st day of life

Gonococcal

• Peaks at 3-5 days after birth
• Has potential to cause loss of vision

Chlamydia

• Peaks from 1wk to 1 month after birth
• Leading cause of preventable blindness in the world

Herpetic

• Peaks at 6-14 days of life
• May lead to keratitis and disseminated infection

Diagnosis

• Gram stain/culture to r/o N. gonorrhea vs C. trachomatis
  • C. trachomatis will have negative gram stain because it is an intracellular parasite.

Treatment

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

Prophylaxis

Erythromycin 0.5% ointment x1 or Tetracycline 1% or Silver Nitrate 1% x1 topical, applied at birth.

Onset 2-4 days: N. gonorrheae

Hyperpurulent. Topical treatment insufficient. Evaluate for Chlamydia. Treat mother and partners.

Ceftriaxone 25-50 mg/kg IV/IM x1 (max 125 mg); cannot be used in neonates requiring calcium-containing fluids OR Cefotaxime 100 mg/kg IV/IM x1. May treat >1 day for severe cases. Always irrigate eyes with saline.

Onset 3-10 days: C. trachomatis

Erythromycin 50 mg/kg/day x10-14 days. Treat mother and partners. 20% have concomitant pneumonia. Azithromycin 20 mg/kg/day x3 days shown to be effective.

Onset 6-14 days: HSV

Consider if serous discharge (not mucopurulent), bulbar injection and corneal dendrites on fluorescein exam. Consult ophtho immediately!

Disposition

• Gonococcal
  • Admit
• Herpetic
  • Admit

See Also

• Conjunctivitis
• Red Eye (Peds)
• Eye Algorithms (Main)

Source

Tintinalli