Neonatal Conjunctivitis

Signs/Symptoms

  • Gonococcal conjunctivitis- hyperacute onset (first 3 days up to 3 weeks of life) with copious, purulent conjunctival discharge
    • marked eyelid edema
    • chemosis
    • Corneal involvement in 33% with corneal ulceration and possible perforation
  • Chlamydial conjunctivitis- subacute onset (5 days to several weeks postpartum) with follicles on everted lower eyelid
    • blood-stained discharge in 33%
    • eyelid edema
    • concurrent lung, nasopharynx, genital infection >50%
    • genital tract involvement is often present but may be asymptomatic

Causes

  • Bacteria (36%)
    • Staphylococcus aureus 16%
    • Moxarella catarrhalis 9%
    • Streptococcus pneumoniae 3%
    • Pseudomonus aeruginosa- rare
    • Nisseria gonorrhoeae (0.4 per 100,000)
  • Chlamydia trachomatis (<40%)
  • Viral (5%)
    • Rhinovirus 2.4%
    • Adenovirus 1.8%
    • Bocavirus 0.6%
    • Herpes simplex, rare

Diagnosis

  • Suspect chlamydial ophthalmia
    • obtain specimin from everted eyelid using Dacron-tipped swab or other specific swab
    • specimin must contain conjunctival cells
    • Direct fluorescent antibody (DFA) is the only FDA-cleared non-culture test.
    • Nucleic acid amplification test (PCR) may be used by CLIA approved labs
    • Culture
  • Suspect gonococcal ophthalmia
    • Gram stain of conjunctival exudate looking for gram-negative intracellular diplococci
    • Culture
  • Dual testing for both of the above is recommended

Treatment

  • Chlamydial ophthalmia neonatorum
    • erythromycin base or ethyl succinate 50 mg/kg/day divided QID x 14 days
    • in infants <6 weeks, watch for infantile hypertropic pyloric stenosis as a side effect
  • Gonococcal ophthalmia neonatorum
    • ceftriaxone 25-50 mg/kg IV or IM x 1 dose (not to exceed 250 mg)
      • consider substitute in neonates with hyuperbilirubinemia
      • do not give if receiving IV calcium
    • substitute: cefotaxime 100 mg/kg IV or IM x 1 dose
  • Coinfection with the above two is common so combined treatment should be considered
  • Other bacteria: consider moxifloxicin TID or QID x 10 days guided by culture with close follow-up
  • Viral- consider antiviral treatment for suspected HSV infection.