Neonatal conjunctivitis

Background

• Vesicles + conjunctivitis = full sepsis eval + acyclovir

Types

Chemical

• Historically due to ocular prophylaxis with silver nitrate
• Occurs on 1st day of life
• Less common now with erythromycin ointment replacing silver nitrate

Gonococcal

• Peaks at 3-5 days after birth
• Has potential to cause loss of vision
• Hyperpurulent

Chlamydia

• Peaks from 1wk to 1 month after birth
• Leading cause of preventable blindness in the world
• May present with otitis and pneumonia with staccato cough

Herpetic

• Peaks at 6-14 days of life
• May lead to keratitis and disseminated infection

Streptococcus/S. Aureus

• 5 wks to 5 yrs

Clinical Features

Gonococcal ophthalmia neonatorum

Chlamydia

• Can range from mild to severe hyperemia with thick mucopurulent discharge

Gonococcal

• May present as typical conjunctivitis or with severe lid edema, cornea ulceration

Differential Diagnosis

Neonatal eye problems

• Nasolacrimal duct obstruction
• Dacrocystitis
• Conjunctivitis
  • Chemical
  • Gonococcal
  • Chlamydia
  • Herpetic
  • Streptococcus/S. Aureus
• Early onset glaucoma
• Uveitis
• Ocular foreign body
• Corneal abrasion
• Ocular trauma
• Ingrown eyelash

Evaluation

• Gram stain/culture to rule out N. gonorrhea vs C. trachomatis
  • C. trachomatis will have negative gram stain because it is an intracellular parasite.

Management

Prophylaxis

Erythromycin 0.5% ointment x1 or Tetracycline 1% or Silver Nitrate 1% x1 topical, applied at birth.

Chemical

• Watchful waiting

Gonococcal (onset 2-4 days)

• Cefotaxime 100mg/kg IV or IM OR ceftriaxone 25-50mg/kg IV or IM x1 (not to exceed 125mg)
  • Cefotaxime is preferred because it does not displace bilirubin
  • Disseminated disease should be suspected until CSF is negative
  • Treat mother and partners
  • Irrigate eyes with saline (topical antibiotics are insufficient and unnecessary)

Chlamydia (onset 3-10 days)

• Azithromycin 20mg/kg PO once daily x 3 days OR
• Erythromycin 50mg/kg PO QD in 4 divided doses x 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)
• Topical treatment is unnecessary

Herpetic (onset 6-14 days)

• Acyclovir 20mg/kg IV q8hr x 14-21d
• Topical antiviral
• Full neonatal sepsis evaluation
• Immediate ophtho consult

Disposition

• Gonococcal
  • Admit
• Herpetic
  • Admit

See Also

• Conjunctivitis
• Red Eye (Peds)
• Eye Algorithms (Main)

References

Authors

Ross Donaldson, Yos Yachivev, Kevin Lu, Jesse Gentiluomo, Neil Young, Daniel Ostermayer