Neonatal Conjunctivitis - A Brief Discussion

Neonatal conjunctivitis is acquired either during birth with passage through the mother’s cervix and vagina, or from cross-infection in the neonatal period.

Etiologies: More common etiologies include Chlamydia trachomatis, viruses (herpes simplex), and bacteria (Staphylococcus aureus, Streptococcal pneumoniae, Haemophilus species).

Clinical Features: 

• Presenting symptoms for Neisseria gonorrhoeae infection include a hyperacute bilateral conjunctivitis with copious purulent discharge, lid swelling, chemosis, and preauricular adenopathy.

            Thick purulent drainage in a newborn diagnosed with neonatal gonococcal conjunctivitis.

• For chlamydial conjunctivitis, the clinical features range from mild swelling with a watery discharge to marked lid swelling with a red and thickened conjunctiva with a blood-stained discharge. 
• Fluorescein staining of herpes simplex conjunctivitis demonstrates epithelial dendrites.
• Blindness can result from gonococcal eye infection in the neonate because the organism can invade the cornea. It is one of the few emergency conjunctival infections.
•  Nasolacrimal duct obstruction is common (up to 20%) in newborns and may present with findings suggestive of conjunctivitis. It is a diagnosis of exclusion in the neonate.

            A scant crusty discharge is seen in this newborn who was diagnosed in follow-up with                         nasolacrimal duct obstruction

Diagnosis: With any form of neonatal conjunctivitis, Gram stain and culture are indicated. Scrapings of the palpebral conjunctiva are more likely to be rewarding than examination of the discharge

itself. 

The “rule of fives” may help predict the most likely bacterial cause.

0-5 days.......................Gonococcus

5 days-5 weeks............Chlamydia

5 weeks-5 years..........Staphylococcus, Streptococcus, Haemophilus

Treatment: Begin treatment in the emergency department (ED) and admit newborns with suspected gonococcal conjunctivitis.

Evaluate concurrently for C trachomatis, since coinfection is common.

Treatment for chlamydial conjunctivitis is based upon a positive diagnostic test. While culture is the gold standard, nucleic acid amplification tests, despite lacking FDA approval, are reported to perform similarly. 

Untreated disease can result in corneal and conjunctival scarring. 

• Bacterial neonatal conjunctivitis that is neither gonococcal nor chlamydial may be treated with erythromycin antibiotic ointment and should be reevaluated in 24 hours.
• Herpes simplex conjunctivitis is treated with intravenous (IV) acyclovir and topical trifluridine. Despite the appearance of a localized herpes infection, there is high risk for central nervous system (CNS) or disseminated infection.

Evaluation of the newborn’s parents should be undertaken in neonatal conjunctivitis due to Gonococcus, Chlamydia, or herpes simplex virus (HSV).

1. Chemical Neonatal Conjunctivitis: Seen on day 1. and is common with use of silver nitrate for prophylaxisis. (erythromycin more commonly used now for this reason). It is self limited and needs no treatment. 

2. N gonorrhoeae Conjunctivitis: Appears between day 2-7, and may cause hyperacute disease with profuse discharge. Treatment is with Ceftriaxone IV. (Caution in hyperbilirubinemia.) Topicals treatment alone is inadequate.

3. C trachomatis Conjunctivitis: Appears between day 3-14. Clinical severity varies and it is a common cause of blindness worldwide. Treatment with Erythromycin. 

4. HSV 1,2: Appears anytime between day 2 &16 and should be suspected if child has any vesicular lesions on body. Treatment is with Vidarabine or trifluridine topically; consider systemic acyclovir.