Continuing Education Activity
Neonatal eye discharge is usually due to congenital nasolacrimal duct obstruction or either chemical or infectious conjunctivitis. Neonatal conjunctivitis, also called ophthalmia neonatorum, typically presents during the first four weeks of life. The infection is usually acquired during delivery and is the most common ocular disease in neonates. Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye. This activity examines the presentation, evaluation, and management of neonatal conjunctivitis and stresses the role of an interprofessional team approach to the care of affected neonates.
Objectives:
- Describe the pathophysiology of neonatal conjunctivitis.
- Describe the history and physical exam findings typically seen in patients with neonatal conjunctivitis.
- Describe treatment considerations for neonatal conjunctivitis.
- Describe how an optimally functioning interprofessional team would coordinate care to enhance management of neonatal conjunctivitis.
Introduction
Neonatal eye discharge is usually due to congenital nasolacrimal duct obstruction or either chemical or infectious conjunctivitis. Neonatal conjunctivitis, also called ophthalmia neonatorum, typically presents during the first four weeks of life. The infection is usually acquired during delivery and is the most common ocular disease in neonates. Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye. This activity examines the presentation, evaluation, and management of neonatal conjunctivitis and stresses the role of an interprofessional team approach to the care of affected neonates.[1][2][3][4][5][4]
Etiology
The age of the baby is an important clue towards the etiology of neonatal conjunctivitis; however, bacterial infections can occur anytime. The following is a summary of occurrences and causes.[6][7][8][5][8]
- First 24 hrs of life: Chemical causes like silver nitrate drops or from prophylactic medicines. like erythromycin drops, gentamicin drops.
- 24 to 48 hrs of life: Bacterial causes are most likely (Neisseria gonorrhoeae is the most common cause, Staphylococcus aureus).
- 5 to 14 days of life: Chlamydia trachomatis
- 6 to 14 days of life: Herpes keratoconjunctivitis
- 5 to 18 days: Pseudomonas aeruginosa
Epidemiology
The incidence of infectious neonatal conjunctivitis ranges from 1% to 2%.
The epidemiology of neonatal conjunctivitis changed when silver nitrate solution was introduced in the 1800s to prevent gonococcal ophthalmia.Chlamydia is the most common infectious agent that causes ophthalmia neonatorum in the United States, where 2% to 40% of neonatal conjunctivitis cases are caused by Chlamydia.
In contrast, the incidence of gonococcal ophthalmia neonatorum has been reduced dramatically and causes less than 1% of cases of neonatal conjunctivitis.[5]
Pathophysiology
Neonates are at higher risk of conjunctivitis due to many predisposing factors, such as:
- Decreased tear production
- Lack of IgA in tears
- Decreased immune function
- Absence of lymphoid tissue in conjunctiva
- Decreased lysozyme activity
Risk factors include premature rupture of membranes, prolonged delivery, prematurity, poor prenatal care, maternal STI, mechanical ventilation, poor hygiene conditions, history of midwife interference, HIV-infected mother.
Neonates at higher risk of congenital lacrimal duct obstruction include those with Down syndrome, Goldenhar Syndrome, clefting syndromes, midline facial anomalies, hemifacial microsomia, and craniosynostosis.[5]
Histopathology
Conjunctival studies will reveal the following for each of the following organisms:
- Chemical conjunctivitis: Negative gram stain with few polymorphonuclear cells.
- Gonococcal conjunctivitis: Gram-negative, kidney-bean shaped, intracellular diplococci on culture with specific media.
History and Physical
A purulent discharge, edema, and erythema of the lids and hyperemia of the conjunctiva are suggestive of conjunctivitis. Discharge can be purulent in bacterial conjunctivitis and watery in viral etiology. Gonorrhea has profuse purulent discharge, Pseudomonas has greenish discharge, and chlamydia can be watery followed with purulent and bloody discharge.
Laterality, unilateral conjunctivitis most often is seen with S. aureus, P. aeruginosa, Herpes simplex, and adenovirus. Bilateral conjunctivitis is seen with infection caused by N. gonorrhea or by use of ocular prophylaxis. Chlamydia usually develops in one eye but effects the other after 2 to 7 days.
The physical exam should include evaluation for red reflex, ulcerations (corneal and conjunctival), and adenopathy. One should also rule out signs of respiratory and systemic infection.
History of STI in the mother increases the risk of chlamydia and gonorrhea. Neonatal conjunctivitis is frequently diagnosed in neonates born to HIV-infected mothers.[5]
Evaluation
Differential diagnosis includes eye discharge that can be conjunctivitis or congenital lacrimal duct obstruction. Other diagnoses may be ocular foreign body, orbital or preseptal cellulitis, entropion, trichiasis, eye trauma (corneal abrasion following delivery), dacryocystitis, keratitis, subconjunctival hemorrhage (breakage of vessels during delivery), congenital anomalies of nasolacrimal system, corneal epithelial disease, neonatal abstinence and congenital glaucoma
Physical exam should evaluate for periorbital edema and adenopathy. Examine both eyes/eyelids for swelling and edema, check conjunctiva for injection (congestion of blood vessels) and chemosis (conjunctival swelling). Check for ulcerations and the presence of red reflex. A purulent discharge, edema and erythema of the lids, as well as injection of the conjunctiva, are suggestive of bacterial conjunctivitis.
Lab studies include Gram stain and culture to check WBC and bacteria, as well as sensitivity and culture of the bacteria isolated (chocolate agar and Thayer-Martin media for gonorrhea and blood agar for another medium). A Giemsa stain should be done for chlamydial suspicion, however chlamydia is now more commonly diagnosed via nucleic acid amplification tests (NAATs) which is less expensive and requires less labor than traditional viral cultures. Of note, newborns with suspected C. trachomatis infection should have samples drawn from both the conjunctivae and oropharynx. Because C. trachomatis is an obligate intracellular organism, swabs should not only be taken from eye discharge but should also include conjunctival epithelial cells if possible.
No imaging and other studies are usually needed, but Fluorescein dye disappearance test can be done to rule out nasolacrimal duct obstruction.[5]
Treatment / Management
General factors important in management include the following:
- Avoid cross contamination by frequent hand washing and wearing gloves
- Irrigate eye with sterile isotonic saline
- Systemic treatment is required for staphylococcal, gonococcal, Chlamydia, Pseudomonas and herpetic conjunctivitis
- Avoid eye patching
- Consider Pediatric iInfectious disease and/or Pediatric Ophthalmology consult
- Chemical conjunctivitis usually resolves with 24 to 72 hours and may be helped with lubrication and artificial tears
Gonococcal conjunctivitis: a medical emergency. Because of PCB resistance, third-generation cephalosporins are the first line antibiotics. It can happen even with appropriate prophylaxis infants delivered to mothers with positive maternal gonococcal infection.[9][10][11][12][13][5][13]
- Ceftriaxone 25-50mg/kg intravenous or intramuscular x 1 dose
- Alternative is cefotaxime single dose of 100 mg/kg
- Isolate the infant during the first 24 hours of parenteral antibiotic therapy
- Test for concomitant HIV and syphilis
- Evaluate for disseminated disease (arthritis, meningitis, sepsis, anorectal infection)
- Consider treating for chlamydia due to high rate of concomitant infection
- Keep a low threshold to evaluate for systemic infection (sepsis, meningitis)
- Ophthalmology consult since gonococcal conjunctivitis can lead to perforation and blindness
- Irrigate the eyes with normal saline at frequent (1 to 2 hour) intervals
- Topical antibiotics are not necessary
Chlamydial conjunctivitis: Recommended prophylaxis does not prevent chlamydial conjunctivitis, and topical treatment is ineffective and unnecessary but may be used as an adjunct to oral therapy. Topical therapy for chlamydial conjunctivitis is generally not effective and has a high failure rate because C. trachomatis is known to colonize the nasopharynx and can thus spread into the lungs if not adequately eradicated.
Erythromycin x 14 days or azithromycin 20 mg/kg/day x 3 days is the recommended treatment. However, the American Academy of Pediatrics still recommends erythromycin because other treatments are not well studied.
A second course is usually required since 1 in 5 cases recur after antibiotic therapy. Pyloric stenosis has been seen in infants less than six weeks old treated with erythromycin.
For infants born to mothers with chlamydia exposure, there is no prophylaxis recommended but it is important to educate the family to monitor for infection including pneumonia.
Herpetic conjunctivitis: Administer topical vidarabine or trifluridine five times a day for ten days, evaluate and treat for systemic herpes, ophthalmology consult is indicated. Systemic treatment with acyclovir is also indicated for SEM (skin eye and mucosa) and central nervous system infection. Ophthalmologic evaluation is recommended as retinopathy, cataracts and chorioretinitis can develop
Isolation: Isolation of a patient is recommended for Pseudomonas, herpes, and gonococcal conjunctivitis.
Lacrimal Duct Obstruction: Most clear spontaneously without treatment. If the problem does not resolve and symptoms persist (usually after 6 to 7 months), the infant should be evaluated by an ophthalmologist.
Differential Diagnosis
- Happy simplex virus keratitis
- Nasolacrimal duct obstruction and epiphora
- Primary congenital glaucoma
- Secondary congenital glaucoma
Enhancing Healthcare Team Outcomes
Neonatal conjunctivitis is not an uncommon problem seen after delivery. When it occurs, the disorder is best managed by an interprofessional team that includes a neonatologist, infectious disease consult, ophthalmologist, pediatrician, pharmacist, and a nurse practitioner. There are many causes of neonatal conjunctivities. Ophthalmia neonatorum (neonatal conjunctivitis) presents during the first four weeks of life with eye discharge and hyperemia and is usually an acquired infection during delivery. If left untreated it can lead to complications (ulceration and perforation of the cornea, blindness, chlamydia pneumonia). In severe cases, treatment should be initiated without waiting for culture results. Neonatal nursing will be likely the first to encounter this condition. They will also be responsible for monitoring once therapy has been initiated. Empirical treatment should be started soon after sending the culture and tapered once the final results are back. The outcomes for most neonates with conjunctivitis are good, particularly with interprofessional intervention and monitoring. [Level 5].[14] (Level V)[5]
Neonatal Conjunctivitis