Neonatal Conjunctivitis

Neonatal conjunctivitis (ophthalmia neonatorum) is conjunctival inflammation within the first 28 days of life.

• Causes and typical onset:
  • Chemical (silver nitrate, erythromycin prophylaxis): within 24 to 36 hours, self-limited.
  • Neisseria gonorrhoeae: 2 to 5 days; sight threatening with corneal perforation.
  • Chlamydia trachomatis: 5 to 14 days; commonest infectious cause in many settings.
  • Other bacteria (Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa): 5 to 18 days.
  • Herpes simplex virus: 1 to 2 weeks; may be part of disseminated disease.
• Maternal sexually transmitted infection, prolonged rupture of membranes and poor antenatal care are risk factors.

• Lid swelling, conjunctival injection, discharge of variable type: copious purulent and hyperacute (gonococcal), mucopurulent with moderate swelling (chlamydial), watery with vesicles on lids (herpetic).
• Gonococcal: rapidly progressive, chemosis, pseudomembrane, corneal ulceration and perforation within days.
• Chlamydial: pseudomembrane, no follicles in the newborn (lymphoid tissue not yet developed), may have pneumonitis (staccato cough, tachypnoea at 4 to 12 weeks) or otitis.
• Herpetic: unilateral lid vesicles, dendritic or geographic keratitis, fever, lethargy, skin lesions.
• Pseudomonas: corneal ulcer and panophthalmitis risk in premature infants.

• Urgent conjunctival swab: Gram stain (intracellular Gram negative diplococci for gonococcus), culture on chocolate and Thayer-Martin agar, nucleic acid amplification for chlamydia and gonococcus, HSV PCR.
• Giemsa stain for chlamydial inclusions in older practice; direct fluorescent antibody or PCR in current practice.
• Examine cornea with fluorescein.
• Screen mother and partner for chlamydia, gonorrhoea, syphilis, HIV and hepatitis B.
• Blood cultures and lumbar puncture if systemic infection (gonococcal sepsis, herpes) suspected.

• Gonococcal: ceftriaxone 25 to 50 mg/kg (maximum 125 mg) intramuscularly or intravenously as a single dose; hospitalise, saline irrigation of the eyes every hour until discharge clears, and treat parents. Neonates with hyperbilirubinaemia need cefotaxime 100 mg/kg single dose in place of ceftriaxone. Topical antibiotics alone are insufficient.
• Chlamydial: oral erythromycin base or ethylsuccinate 50 mg/kg/day in four divided doses for 14 days (a second course may be required, efficacy about 80 percent); alternative azithromycin 20 mg/kg once daily for 3 days. Monitor for infantile hypertrophic pyloric stenosis. Treat both parents (azithromycin 1 g orally single dose).
• Herpetic: intravenous aciclovir 20 mg/kg every 8 hours for 14 to 21 days, with topical ganciclovir 0.15 percent gel or trifluridine 1 percent five times daily for the eye; follow with oral aciclovir suppression.
• Other bacteria: topical antibiotics (erythromycin 0.5 percent ointment or gentamicin 0.3 percent drops four times daily for 7 days); for Pseudomonas use fortified or fluoroquinolone drops plus systemic therapy.
• Prophylaxis at birth: erythromycin 0.5 percent ointment or tetracycline 1 percent ointment single application to each eye, or povidone iodine 2.5 percent drops. Prophylaxis does not reliably prevent chlamydial disease.
• Antenatal screening and treatment of maternal sexually transmitted infections, and caesarean section for maternal active genital herpes.
• Follow up daily until improved and then at 1 to 2 weeks to monitor for corneal sequelae and amblyopia.