BASICS

DESCRIPTION

Conjunctivitis occurring in the first 4 weeks of life

EPIDEMIOLOGY

Incidence

• US:

– Gonococcal: 0.3/1,000 births

– Chlamydial: 8.2/1,000 births

• Developing countries: 15–60% of live births

Gonorrhea is a major cause of childhood blindness in some countries.

RISK FACTORS

• Maternal systemic infection

• Premature or prolonged rupture of placental membranes

• Low birth weight

• Nasal cannula, mask, or ventilator use

• Ophthalmologic examination and speculum use

• Use of silver nitrate or gentamicin for prophylaxis

• Failure to use prophylaxis

• Folk treatments including urine instilled into the eyes

Genetics

No known contribution

GENERAL PREVENTION

• Proper prenatal care

• Universal precautions and maintenance of sterility

• Ocular prophylaxis immediately after birth:

Preferably 0.5% erythromycin ointment (1)[A]

– Povidone-iodine solution is effective, safe, and cost effective but not yet approved in the US or Canada (2)[A], (3)[A].

– Respiratory organisms through respiratory supportive care (especially intubation or mask)

– Discourage folk treatments of conjunctivitis

PATHOPHYSIOLOGY

• Inoculation by maternal or iatrogenic routes

• Deficient infant immune defense mechanisms

• Chemical irritation: Silver nitrate and gentamicin ointment

ETIOLOGY

• Infectious: Gram-negative enteric bacteria, Staphylococcus aureus (including methicillin-resistant strains), Neisseria gonorrhea, Streptococcus pneumoniae, Chlamydia trachomatis, and herpes simplex virus

• Noninfectious: Silver nitrate toxicity, topical gentamicin toxicity

COMMONLY ASSOCIATED CONDITIONS

• Maternal infection (known or unknown)

• Premature or prolonged rupture of placental membranes

• Gonorrhea: Corneal perforation

• Herpes: Skin lesions, encephalitis, and viral sepsis

• Gentamicin toxicity: Lid skin erosions

DIAGNOSIS

HISTORY

• Maternal/birth

– Quality of prenatal care

– Systemic infection and history of sexually transmitted disease

– Paternal or maternal genital discharge

– Premature or prolonged rupture of placental membranes

• Infant

– Low birth weight

– Systemic disease and immunodeficiency

– Prophylaxis not given

– Use of silver nitrate or gentamicin prophylaxis

– Ocular examination, use of nonsterile speculum/instruments

– Requiring respiratory support

PHYSICAL EXAM

• Systemic physical examination

• Complete ocular exam including dilated retinal examination to rule out intraocular involvement if infectious etiology

– Eyelids: Edema and erythema, lid skin erosions in gentamicin toxicity

– Conjunctiva: Chemosis and injection (Note: Absence of conjunctival injection suggests nasolacrimal duct obstruction as cause of discharge)

– Discharge: Bacterial infection and silver nitrate/gentamicin toxicity: Mucopurulent, viral infection may be clear discharge

– Cornea

HSV: Dendrite, stromal infiltrate, or geographic erosion of corneal epithelium

Gonorrhea: Ulcer, possible perforation

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

• Urgent Gram stain to identify gonorrhea

• Culture for bacteria, chlamydia, and viruses

• Coordinate with lab for special stains (Giemsa for chlamydia), culture media (chocolate agar for gonorrhea), and rapid tests (for chlamydia)

Follow-up & special considerations

• If sexually transmitted disease is identified, mother and her sexual partners should be referred for testing and, as needed, for treatment.

• If sexually transmitted disease is identified, test child for other organisms: HIV and syphilis.

Imaging

• CT/MRI of brain if herpes simplex virus is identified or child is systemically unwell

• CT/MRI if concern about secondary periorbital or orbital cellulitis

Diagnostic Procedures/Other

Lumbar puncture if child is systemically unwell or concern about herpes simplex encephalitis

Pathological Findings

• Biopsy not typically performed

• Gonorrhea: Gram stain shows intracellular gram-negative diplococci

• Chlamydia: Intracellular inclusions in conjunctival epithelial scraping

DIFFERENTIAL DIAGNOSIS

• Nasolacrimal duct obstruction

• Neonatal blepharitis/blepharoconjunctivitis

• Diffuse retinoblastoma

• Neonatal leukemia with ocular involvement

• Uveitis due to prenatal infection

• Epiphora due to congenital/infantile glaucoma

TREATMENT

MEDICATION

• Chlamydia trachomatis

– Systemic therapy necessary to prevent respiratory infection (pneumonitis)

– Erythromycin estolate 40–50 mg/kg per day in 4 divided doses for 14–21 days; maximum dose: 2 g/day

– Topical therapy optional, erythromycin ointment b.i.d.

• Neisseria gonorrhea

– Single dose of ceftriaxone (25–50 mg/kg, not to exceed 125 mg) IV or IM in healthy infant with uncomplicated conjunctivitis

– Cefotaxime (100 mg/kg) IV or IM, also acceptable in uncomplicated cases

– Topical therapy: Topical antibiotic, optional

– Note: Penicillin alone is not a satisfactory treatment.

• Herpes simplex virus

– Acyclovir 60 mg/kg per day in 3 divided doses IV for 14–21 days and possibly longer, as determined by the pediatrician.

– Topical trifluridine 1% may be used every 1–2 hours (not to exceed 9 times per day) for 1–2 week and tapered.

– Topical steroids should be avoided.

• Other bacterial

– Therapy based on Gram stain and culture results

– Consider coverage for MRSA (4)[C].

• Chemical

– Discontinue offending agent.

– Treat for inflammatory response and/or secondary infection.

– Usually self-limited

ADDITIONAL TREATMENT

General Measures

Saline irrigation every 2 hours to clear mucopurulent discharge

Issues for Referral

• Cornea consult if perforation or impending perforation

– Cornea consult if nonresolving corneal lesion due to herpes

Additional Therapies

As indicated by medical condition and etiologic agent.

COMPLEMENTARY & ALTERNATIVE THERAPIES

• Not indicated

• Do not use breast milk or urine in eyes.

SURGERY/OTHER PROCEDURES

Not typically necessary (except for trichiasis and scarring as long term result of chronic chlamydia trachomatis).

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Pediatric consultation if child systemically unwell or other concerns.

Admission Criteria

• Systemically unwell

• Urgent hospital admission suggested for all purulent suspected bacterial conjunctivitis until etiology clear and for neonatal herpes simplex conjunctivitis.

IV Fluids

As needed.

Nursing

Appropriate isolation/precautions

Discharge Criteria

When parenteral antibiotics are completed, the child is systemically well, and the parents are able to continue care as needed.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

As needed for amblyopia therapy, if corneal scar is present.

Patient Monitoring

Visual acuity as needed for amblyopia therapy, if corneal scar is present.

DIET

No special dietary recommendations.

PATIENT EDUCATION

If sexually transmitted disease, mother and her sexual partners should be referred for diagnosis, treatment, and counseling.

PROGNOSIS

• Uncomplicated–excellent

• Complicated with corneal scar–variable depending upon severity and compliance with amblyopia therapy

• Gonorrhea corneal perforation–poor prognosis

COMPLICATIONS

Permanent vision loss from amblyopia due to corneal scar

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