eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Neonatal: Treatment & Medication

Author: Kalpana K Jatla, MD, Private Practice, Clarity Eye Center
Coauthor(s): Robert William Enzenauer, MD, MPH, Professor, Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center; Feng Zhao, MD, PhD, Staff Physician, Department of Ophthalmology, Emory Cartersville Medical Center
Contributor Information and Disclosures

Updated: Nov 17, 2008

Treatment

Medical Care

• Prophylaxis
  • According to the 1997 Red Book, topical 1% silver nitrate, 0.5% erythromycin, and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection in newborn infants.¹ Each is available in single-dose tubes.
  • Studies indicate that 2.5% povidone-iodine solution also may be useful in preventing neonatal ophthalmia, but a product for this purpose is not commercially available.
  • Silver nitrate appears to be the best agent in areas where the incidence of penicillinase-producing N gonorrhoeae (PPNG) is significant. Neonates born to mothers with active gonococcal infection should receive a single IM injection of aqueous penicillin G.
  • A study showed that topical tetracycline and silver nitrate reduced the incidence of chlamydial ophthalmia neonatorum but did not eradicate the nasopharyngeal colonization or pneumonia. Such treatments possess the potential for not treating disseminated disease, so systemic treatment is required for gonococcal, chlamydial, and herpetic ophthalmia neonatorum.
• Medical treatment
  • Specific treatment is available for the various causes of neonatal conjunctivitis. Preliminary presumptive treatment pending culture confirmation should be based on the clinical picture and the findings on Gram, Giemsa, and Papanicolaou stains.
  • To confirm the presence of a sexually transmitted disease in the neonate, examine and treat the mother and her sexual partner(s). If necessary, therapy can be modified when the results of culture and sensitivity are known.
  • Bacterial conjunctivitis rarely fails to respond to treatment.
  • Emphasize that prompt treatment of gonococcal conjunctivitis is important, since this organism can penetrate an intact corneal epithelium and rapidly cause corneal ulceration. Because of the rapid progression of gonococcal conjunctivitis, patients with acute neonatal conjunctivitis should be treated for gonococcal conjunctivitis until culture results are available; the treatment is altered according to the laboratory results.
  • The treatment prior to laboratory results should include topical erythromycin ointment and IV or IM third-generation cephalosporin.
  • Pediatric consultation is indicated.
• Chemical conjunctivitis: Treatment is not necessary. Lubrication with artificial tear preparations may ease mild discomfort.
• Bacterial conjunctivitis
  • Erythromycin or bacitracin ointment for gram-positive organisms
  • Gentamicin or tobramycin drops for gram-negative organisms
  • Fortified topical antibiotics for Pseudomonas
  • IV penicillin G for N gonorrhoeae
  • Because of the prevalence of penicillin-resistant N gonorrhoeae, the treatment of choice for this organism is topical erythromycin ointment and systemic, third-generation cephalosporin (ceftriaxone 30-50 mg/kg/d in divided doses IV or IM, not to exceed 125 mg).
  • Infants with gonococcal ophthalmia should have their eyes irrigated with saline frequently until the discharge is eliminated. A single dose of cefotaxime (100 mg/kg IV or IM) is an alternative treatment.
• Chlamydial conjunctivitis
  • This infection is treated with oral erythromycin (50 mg/kg/d divided qid).
  • Topical treatment alone is ineffective. Topical erythromycin ointment may be beneficial as an adjunctive therapy.
  • Since the efficacy of systemic erythromycin therapy is approximately 80%, a second course sometimes is required.
• Herpetic conjunctivitis
  • Neonates with a suspected herpetic simplex infection should be treated with systemic acyclovir to reduce the chance of a systemic infection.
  • An effective dose is 30 mg/kg/day IV divided tid, but most experts recommend higher doses (45-60 mg/kg/d).
  • The recommended minimal duration is 14 days, but a course as long as 21 days may be required.
  • Infants with neonatal HSV keratitis should receive a topical ophthalmic drug, most commonly 1% trifluridine drops or 3% vidarabine ointment.

Consultations

Pediatrician or pediatric infectious specialist

Medication

The goals of pharmacotherapy are to reduce morbidity and to eliminate the infection.

Antimicrobial agents

Suppress the growth of other microorganisms and eventually may destroy them.

Erythromycin (E-Mycin, Eryc, Ery Tab)

Treats C trachomatis infection. Systemic treatment is necessary. Topical antimicrobial therapy not necessary (but may help) if systemic therapy given.

Tetracycline, 1% ophthalmic ointment (Sumycin)

A bacteriostatic derivative of polycyclic naphthacene carboxamide is an alternative for chlamydial infection.

Penicillin G (Pfizerpen)

The choice for penicillin-susceptible N gonorrhoeae infection. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Bacitracin (Baciguent, AK-Tracin)

Ointment for gram-positive cocci. Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.

Ceftriaxone (Rocephin)

For penicillinase-producing N gonorrhoeae. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.

Cefotaxime (Claforan)

An alternative treatment for N gonorrhoeae. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth.
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

Gentamicin (Garamycin, Gentacidin)

Systemic gentamicin is another alternative for penicillinase-producing N gonorrhoeae. Topical gentamicin also is used for other gram-negative bacterial infections.

Tobramycin (AKTob, Tobrex)

Ointment or drops for gram-negative bacilli. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane.
Available as a solution, ointment, and lotion.

Silver nitrate 1% ophthalmic solution

Has been used to prevent gonorrheal ophthalmia neonatorum.

Povidone-iodine ophthalmic solution 2.5%

An antibacterial agent with broad antibacterial and antiviral activity. No bacteria are known to be resistant to povidone-iodine. Povidone-iodine is far less expensive and less toxic than agents currently used to prevent neonatal conjunctivitis.

Antiviral agents

Therapy of viral infections begins with mechanical debridement of the involved rim along with a rim of normal epithelium. This is followed by the topical instillation of antiviral medications such as vidarabine, trifluridine, and acyclovir.

Vidarabine ointment (Vira-A)

Topical idoxuridine that interferes with early steps of viral DNA synthesis.
This ointment may stay in an infant's eye better than trifluridine drops, which tend to be rapidly cried out.

Acyclovir (Zovirax)

Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks.

1% Trifluridine ophthalmic solution (Viroptic)

A purine nucleoside, the DOC for herpes simplex keratitis, which is superior to either vidarabine or idoxuridine. Trifluridine has better penetration and is more effective. Inhibits viral replication by incorporating into viral DNA in place of thymidine. If no response in 7-14 d, consider other treatments.

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