2-04: Neonatal Conjunctivitis (Ophthalmia Neonatorum)

Clinical Summary

Neonatal conjunctivitis is acquired either during birth with passage through the mother’s cervix and vagina or from cross-infection in the neonatal period. Presenting symptoms for Neisseria gonorrhoeae infection include a hyperacute bilateral conjunctivitis with copious purulent discharge, lid swelling, chemosis, and preauricular adenopathy.

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

Management and Disposition

With any form of neonatal conjunctivitis, Gram stain and culture are indicated. Begin treatment in the ED, and admit newborns with suspected gonococcal conjunctivitis. Evaluate concurrently for C trachomatis, since coinfection is common. Nucleic acid amplification testing (NAAT) is highly sensitive in confirming gonococcal or chlamydial infection.

Treatment for chlamydial conjunctivitis is based on a positive diagnostic test. While culture is the gold standard, NAATs, despite lacking US Food and Drug Administration 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).

Pearls

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

   Table Graphic Jump Location

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   0-5 days	Gonococcus
   5 days-5 weeks	Chlamydia
   5 weeks-5 years	Staphylococcus, Streptococcus, Haemophilus

2. 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.

3. Nasolacrimal duct obstruction is common ...