Neonatal conjunctivitis comprises a number of entities, including chemical irritation caused by antimicrobial prophylaxis (most common cause), infections acquired through direct contact between the neonate and the mother's cervix and vagina during delivery, and infections transmitted by cross-inoculation in the neonatal period. Common causative organisms include Chlamydia trachomatis (most common), Neisseria gonorrhoeae (most threatening), Haemophilus species, Streptococcus species, Staphylococcus aureus, and viruses such as Herpes simplex (HSV). Clinical findings in include drainage, conjunctival hyperemia, chemosis, and lid edema. Timing of presentation following birth and maternal findings often are useful in determining the most likely etiology.
Emergency Department Treatment and Disposition
As with any focal infection in the neonate, a careful evaluation for systemic involvement is indicated. When neonatal conjunctivitis is observed, cultures and smears are mandatory, and should be followed immediately by treatment, in consultation with a pediatrician or infectious disease specialist. Scrapings of the palpebral conjunctiva for cultures and Gram stain are more revealing than examination of the discharge itself. Corneal examination with fluorescein staining should be done to detect the dendritic lesions of HSV.
Neonatal Conjunctivitis (Ophthalmia Neonatorum). Copious purulent drainage in a newborn with neonatal gonococcal conjunctivitis. (Reprinted with permission of the American Academy of Ophthalmology. Eye Trauma and Emergencies: A Slide-Script Program. San Francisco, 1985.)
TABLE 2.1 SUMMARY OF ETIOLOGIES OF NEONATAL CONJUNCTIVITIS |Favorite Table|Download (.pdf)
TABLE 2.1 SUMMARY OF ETIOLOGIES OF NEONATAL CONJUNCTIVITIS
|Etiologic Agent||Time of Onset||Clinical Features||Treatment|
|Chemical||Day 1||Common with silver nitrate; erythromycin more commonly used now for this reason||Self-limited|
|N gonorrhoeae||Day 2-7||May cause hyperacute disease with profuse discharge||Ceftriaxone 25-50 mg/kg IV NTE 125 mg. Caution in hyper-bilirubinemia. Topicals alone inadequate|
|C trachomatis||Day 3-14||Clinical severity varies. Common cause of blindness worldwide||Erythromycin 12.5 mg PO q6h × 14 days|
|HSV 1,2||Day 2-16||Should be suspected if child has any vesicular lesions on body||Vidarabine or trifluridine topically; consider adding systemic acyclovir|
|Other bacterial||Day 2 and up||Empiric treatment based on Gram stain||Erythromycin ointment for gram-organisms positive; gentamicin or tobramycin ointment for gram-negative|
Etiologies of neonatal conjunctivitis may be difficult to ascertain on clinical grounds, and though chemical irritation is most common, aggressive work-up and treatment is mandatory in all cases due to the potentially devastating nature of gonococcal conjunctivitis.
The "rule of fives" is a mnemonic device for predicting the most likely bacterial etiology; however, there is considerable overlap in times to onset.
0 to 5 days: N gonorrhoeae
5 days to 5 weeks: Chlamydia
5 weeks to 5 years: Streptococcus or Haemophilus influenzae
Although an uncommon cause of conjunctivitis, HSV may cause a concomitant life-threatening systemic infection in the neonate. A high index of suspicion should be ...