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

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
  • 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

Eye Algorithms

References

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