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Neonatal conjunctivitis

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Neonatal conjunctivitis
Other names: Ophthalmia neonatorum; pink eye in newborns; natal conjunctivitis
A newborn with gonococcal neonatal conjunctivitis
SpecialtyPediatrics
SymptomsSwollen tender eyelid, redness and drainage from the eye[1]
ComplicationsBlindness[2]
Usual onsetFew days to several weeks after birth[1]
CausesInfection, irritation, blocked tear duct[1]
Risk factorsInfected mother[3]
Diagnostic methodBased on symptoms, supported by bacterial culture[2][3]
Differential diagnosisEye foreign body, orbital cellulitis, preseptal cellulitis, entropion, corneal abrasion, dacryocystitis, keratitis, subconjunctival bleed, neonatal abstinence, congenital glaucoma[4]
PreventionErythromycin eye drops[1]
TreatmentOften antibiotic[1]
MedicationCefotaxime, azithromycin, acyclovir[3]
FrequencyRelatively common[4]

Neonatal conjunctivitis is inflammation of the outer aspect of the eye in the first 28 days of life.[2] Symptoms may include a swollen or tender eyelid, with redness and drainage from the eye.[1] The drainage may be watery or yellow.[5] Complications without treatment may include blindness.[2]

Causes include infection, irritation, or a blocked tear duct.[1] Infectious causes include gonorrhea, chlamydia, and herpes; which are generally acquired during passage through the birth canal.[1] Other infections may include Staphylococcus aureus, Streptococcus pneumoniae, and Pseudomonas.[2] Common irritants include silver nitrate, used within the prior 48 hours to prevent infection.[2] Diagnosis is based on symptoms and supported by gram stain and bacterial culture.[2][3]

Antibiotic drops, typically erythromycin or silver nitrate, are applied to the eyes within a few hour of birth as prevention.[1][3] This is required by law in most US States.[1] When an infection is suspected, treatment is often with chloramphenicol applied to both eyes.[5] Antibiotics by mouth, such as erythromycin; or by injection, such as cefotaxime, may also be used.[1][5] Cases due to irritation usually resolve within 2 to 4 days.[3]

Neonatal conjunctivitis is relatively common; though, rates of diseases vary around the world.[4][2] In the United States about 1 to 2% of babies are affected.[4] While once common, cases due to sexually transmitted infections are now uncommon in developed countries; though, remain common in low and middle income countries.[2] In the late 1800s it was one of the most common causes of blindness in Europe.[2]

Signs and symptoms

Neonatal conjunctivitis due to Gonococcus infection, the eye lids are swollen

Neonatal conjunctivitis by definition presents during the first month of life. Signs and symptoms include:[citation needed]

  • Pain and tenderness in the eyeball
  • Conjunctival discharge: purulent, mucoid or mucopurulent (depending on the cause)
  • Conjunctival hyperaemia and chemosis, usually also with swelling of the eyelids
  • Corneal involvement (rare) may occur in herpes simplex ophthalmia neonatorum

Timing of onset

Chemical causes: Right after delivery

Neisseria gonorrhoeae: Delivery of the baby until 5 days after birth (early onset)

Chlamydia trachomatis: 5 days after birth to 2 weeks (late onset – C. trachomatis has a longer incubation period)[6]

Complications

Untreated cases may develop corneal ulceration, which may perforate, resulting in corneal opacification and staphyloma formation.

Cause

Non-infectious

Chemical irritants such as silver nitrate can cause chemical conjunctivitis, usually lasting 2–4 days. Thus, prophylaxis with a 1% silver nitrate solution is no longer in common use.[7] In most countries, neomycin and chloramphenicol eye drops are used, instead.[8][9] However, newborns can suffer from neonatal conjunctivitis due to reactions with chemicals in these common eye drops.[10] Additionally, a blocked tear duct may be another noninfectious cause of neonatal conjunctivitis.[citation needed]

Infectious

Scanning electron micrograph of Neisseria gonorrhoeae bacteria

The two most common infectious causes of neonatal conjunctivitis are N. gonorrheae and Chlamydia, typically acquired from the birth canal during delivery. However, other different bacteria and viruses can be the cause, including herpes simplex virus (HSV 2), Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus pneumoniae.[citation needed]

Ophthalmia neonatorum due to gonococci (N. gonorrhoeae) typically manifests in the first 5 days after birth and is associated with marked bilateral purulent discharge and local inflammation. In contrast, conjunctivitis secondary to infection with C. trachomatis produces conjunctivitis 3 days to 2 weeks after delivery. The discharge is usually more watery in nature (mucopurulent) and less inflamed. Babies infected with chlamydia may develop pneumonitis (chest infection) at a later stage (range 2–19 weeks after delivery). Infants with chlamydia pneumonitis should be treated with oral erythromycin for 10–14 days.[11]

Diagnosis is performed after taking swab from the infected conjunctivae.[citation needed]

Diagnosis

Differential diagnosis

The DDx for this form of conjunctivitis includes the following:[12]

  • Congenital lacrimal duct obstruction
  • Preseptal cellulitis
  • Eye trauma

Prevention

Antibiotic ointment is typically applied to the newborn's eyes within 1 hour of birth as prevention against gonococcal ophthalmia.[13] This may be erythromycin, tetracycline, or rarely silver nitrate[13] or Argyrol (mild silver protein).

Treatment

Prophylaxis needs antenatal, natal, and postnatal care.

  • Antenatal measures include thorough care of mother and treatment of genital infections when suspected.
  • Natal measures are of utmost importance, as most infection occurs during childbirth. Deliveries should be conducted under hygienic conditions taking all aseptic measures. The newborn baby's closed lids should be thoroughly cleansed and dried.
  • If the cause is determined to be due to a blocked tear duct, gentle palpation between the eye and the nasal cavity may be used to clear the tear duct. If the tear duct is not cleared by the time the newborn is 1 year old, surgery may be required.[14]
  • Postnatal measures include:
    • Use of 1% tetracycline ointment, 0.5% erythromycin ointment, or 1% silver nitrate solution (Credé's method) into the eyes of babies immediately after birth
    • Single injection of ceftriaxone IM or IV should be given to infants born to mothers with untreated gonococcal infection.
    • Curative treatment as a rule, conjunctival cytology samples and culture sensitivity swabs should be taken before starting treatment.
  • Chemical ophthalmia neonatorum is a self-limiting condition and does not require any treatment.
  • Gonococcal ophthalmia neonatorum needs prompt treatment to prevent complications. Topical therapy should include:
    • Saline lavage hourly till the discharge is eliminated
    • Bacitracin eye ointment four times per day (because of resistant strains, topical penicillin therapy is not reliable, but in cases with proven penicillin susceptibility, penicillin drops 5000 to 10000 units per ml should be instilled every minute for half an hour, every five minutes for next half an hour, and then half-hourly till the infection is controlled.)
    • If the cornea is involved, then atropine sulfate ointment should be applied.
    • The advice of both the pediatrician and ophthalmologist should be sought for proper management.

Systemic therapy: Newborns with gonococcal ophthalmia neonatorum should be treated for 7 days with ceftriaxone, cefotaxime, ciprofloxacin, or crystalline benzyl penicillin.

  • Other bacterial ophthalmia neonatorum should be treated by broad-spectrum antibiotics drops and ointment for 2 weeks.
  • Neonatal inclusion conjunctivitis caused by C. trachomatis should be treated with oral erythromycin.[15] Topical therapy is not effective and also does not treat the infection of the nasopharynx.[16][17][18]
  • Herpes simplex conjunctivitis should be treated with intravenous acyclovir for a minimum of 14 days to prevent systemic infection.[19]

Epidemiology

Rates vary widely by location. In England there was 257 (95% confidence interval: 245 to 269) per 100,000 in 2011.[20]

See also

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 "Pink Eye in Newborns". Conjunctivitis (Pink Eye). 15 April 2024. Retrieved 13 October 2024.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 "Ophthalmia neonatorum". patient.info. Retrieved 13 October 2024.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 "Neonatal Conjunctivitis - Neonatal Conjunctivitis". Merck Manual Professional Edition. Archived from the original on 6 December 2023. Retrieved 13 October 2024. Archived 6 December 2023 at the Wayback Machine
  4. ↑ 4.0 4.1 4.2 4.3 Makker, K; Nassar, GN; Kaufman, EJ (January 2024). "Neonatal Conjunctivitis". StatPearls. PMID 28722870.
  5. ↑ 5.0 5.1 5.2 "Eye infections in the neonate: Ophthalmia Neonatorum and the management of systemic Gonococcal and Chlamydial infections". www.clinicalguidelines.scot.nhs.uk. Retrieved 13 October 2024.
  6. ↑ Tan, Aik-Kah (2019-01-09). "Ophthalmia Neonatorum". New England Journal of Medicine. 380 (2): e2. doi:10.1056/NEJMicm1808613. PMID 30625059. S2CID 58654865.
  7. ↑ Mallika, PS; Asok, T; Faisal, HA; Aziz, S; Tan, AK; Intan, G (2008-08-31). "Neonatal Conjunctivitis – a Review". Malaysian Family Physician. 3 (2): 77–81. ISSN 1985-207X. PMC 4170304. PMID 25606121.
  8. ↑ Edwards, Keith H. (2009). Optometry: Science, Techniques and Clinical Management. Elsevier Health Sciences. p. 102. ISBN 978-0750687782. Archived from the original on 2017-03-07.
  9. ↑ "Chloramphenicol". The American Society of Health-System Pharmacists. Archived from the original on 2015-06-24. Retrieved Aug 1, 2015. Archived 2015-06-24 at the Wayback Machine
  10. ↑ "Conjunctivitis in Children". www.hopkinsmedicine.org. Johns Hopkins Medicine Health Library. Archived from the original on 2020-08-04. Retrieved 2016-11-11. Archived 2020-08-04 at the Wayback Machine
  11. ↑ "Red Book – Report of the Committee on Infectious Diseases, 29th Edition". The American Academy of Pediatrics. Archived from the original on 2014-08-21. Retrieved 2007-07-12. Archived 2014-08-21 at the Wayback Machine
  12. ↑ Makker, Kartikeya; Nassar, George N.; Kaufman, Evan J. (2022). "Neonatal Conjunctivitis". StatPearls. StatPearls Publishing. Archived from the original on 2 April 2022. Retrieved 6 April 2022. Archived 2 April 2022 at the Wayback Machine
  13. ↑ 13.0 13.1 Matejcek, A; Goldman, RD (November 2013). "Treatment and prevention of ophthalmia neonatorum". Canadian Family Physician. 59 (11): 1187–90. PMC 3828094. PMID 24235191.
  14. ↑ "Conjunctivitis | Pink Eye | Newborns". www.cdc.gov. Archived from the original on 2016-11-12. Retrieved 2016-11-11. Archived 2016-11-12 at the Wayback Machine
  15. ↑ "Conjunctivitis". The Lecturio Medical Concept Library. 23 July 2020. Archived from the original on 10 July 2021. Retrieved 10 July 2021. Archived 10 July 2021 at the Wayback Machine
  16. ↑ American Academy of Pediatrics. "Chlamydia trachomatis". In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW (Ed), Elk Grove Village, IL p. 288.
  17. ↑ Heggie Alfred D.; et al. (1985). "Topical sulfacetamide vs oral erythromycin for neonatal chlamydial conjunctivitis". American Journal of Diseases of Children. 139 (6): 564–66. doi:10.1001/archpedi.1985.02140080034027. PMID 3890519.
  18. ↑ Hammerschlag Margaret R.; et al. (1982). "Longitudinal studies on chlamydial infections in the first year of life". The Pediatric Infectious Disease Journal. 1 (6): 395–401. doi:10.1097/00006454-198211000-00007. PMID 7163029. S2CID 27570122.
  19. ↑ "Neonatal Conjunctivitis Treatment & Management: Treatment of Neonatal Herpetic Conjunctivitis". Archived from the original on 2018-07-03. Retrieved 2013-08-11. Archived 2018-07-03 at the Wayback Machine
  20. ↑ Dharmasena, A; Hall, N; Goldacre, R; Goldacre, MJ (August 2015). "Time trends in ophthalmia neonatorum and dacryocystitis of the newborn in England, 2000-2011: database study". Sex Transm Infect. 91 (5): 342–5. doi:10.1136/sextrans-2014-051682. PMID 25512672. S2CID 36391207.

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External resources

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