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Neonatal Conjunctivitis Treatment & Management

  • Author: Emily A McCourt, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc  more...
 
Updated: Jan 11, 2016
 

Approach Considerations

Specific treatment is available for each cause 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.

Prior to birth, consider the risk of transmission of chlamydial, gonococcal, herpetic, and streptococcal pathogens to the fetus during vaginal delivery. Obtain cervical cultures if indicated and manage appropriately, including the possibility of a Caesarian delivery.

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.

The treatment prior to laboratory results should include topical erythromycin ointment and an IV or IM third-generation cephalosporin. 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.

In cases of chlamydial conjunctivitis, systemic treatment is necessary because of the significant risk for life-threatening pneumonia.

Infants with a potentially sexually transmitted disease, such as gonorrhea or chlamydia, should undergo evaluation for other sexually transmitted diseases, such as syphilis and HIV,[13] as should the mother and her sexual partner(s).

Newborns with conjunctivitis are at risk for secondary infections, such as pneumonia, meningitis, and septicemia, which can lead to sepsis and death and thus should be admitted for full workup and treatment.

Bacterial conjunctivitis rarely fails to respond to treatment.

A consultation can be made with a pediatrician or pediatric infectious specialist in neonatal conjunctivitis, and the patient should be seen daily until response to treatment is confirmed.

Discharged patients should continue the treatment, according to clinical presentations and available culture results. Treatment may be modified later per culture results.

Avoid eye patching.

Treatment of neonatal chemical conjunctivitis is not necessary. Lubrication with artificial tear preparations may ease mild discomfort. 

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Neonatal Chlamydial Conjunctivitis

This infection is treated with oral erythromycin (50 mg/kg/d divided qid) for 14 days.

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.

Systemic treatment is important in cases of chlamydial conjunctivitis since topical therapy is ineffective in eradicating the bacteria in the nasopharynx of the infant, which could cause a life-threatening pneumonia if left untreated.

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Treatment of Neonatal Herpetic Conjunctivitis

Neonates with a suspected herpes simplex infection should be treated with systemic acyclovir to reduce the risk of a systemic infection.

An effective dose is 60 mg/kg/day IV divided tid.

The recommended minimal duration is 14 days, but a course as long as 21 days may be required.

Infants with neonatal HSV keratitis should also receive a topical ophthalmic drug, most commonly 1% trifluridine drops or 3% vidarabine ointment. Topical ganciclovir 0.15% gel is now also available, although none of these topical agents is specifically approved for neonatal use.[15]

Topical antibiotics can also be considered to prevent secondary bacterial infections in cases with significant epithelial defects. 

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Prophylaxis

According to the 2012 Red Book, topical 0.5% erythromycin and 1% tetracycline are considered equally effective for prophylaxis of ocular gonorrhea infection in newborn infants. Each is available in single-dose tubes. Topical silver nitrate, povidone-iodine, and erythromycin are all effective in the prevention of nongonococcal nonchlamydial neonatal conjunctivitis. There is no agent that is currently effective in preventing the transmission of C trachomatis from mother to baby.[14] This is a change from the 2009 Red Book which stated that erythromycin or silver nitrate could prevent vertical transmission.[8]

Povidone-iodine solution (2.5%) is effective in preventing neonatal ophthalmia. Povidone-iodine is widely used outside of the United States. It is approved by the US Food and Drug Administration (FDA), but it is not commercially available in this country.[14]

Silver nitrate is the best agent in areas where the incidence of penicillinase-producing N gonorrhoeae (PPNG) is significant.[10]

The recommendations in the 2012 Redbook are for 2 drops of 1% silver nitrate or a 1 cm ribbon of antibiotic ointment (either erythromycin or tetracycline) placed into the lower conjunctival sac; both acceptable regimens for the prophylaxis of neonatal conjunctivitis.[4] Erythromycin ointment is considered the best regimen for prophylaxis against neonatal conjunctivitis because of its efficacy against gonococcal and nongonococcal nonchlamydial pathogens and owing to its low incidence of causing a chemical conjunctivitis.[10]  

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Contributor Information and Disclosures
Author

Emily A McCourt, MD Assistant Professor of Pediatric Ophthalmology and Adult Strabismus, Children's Hospital Colorado, University of Colorado Denver School of Medicine

Emily A McCourt, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Feng Zhao, MD, PhD Private Practice, Allatoona Eye Institute

Feng Zhao, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Georgia Society of Ophthalmology, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Robert William Enzenauer, MD, MPH, MBA, MSS Professor, Department of Ophthalmology, University of Colorado School of Medicine; Chairman, Department of Ophthalmology, Children's Hospital

Robert William Enzenauer, MD, MPH, MBA, MSS is a member of the following medical societies: American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Association for Physician Leadership, American Academy of Ophthalmology

Disclosure: CLEAR DONOR: Received consulting fee from Clear Donor for consulting; Partner received salary from Clear Donor for employment.

Kalpana K Jatla, MD Private Practice, Clarity Eye Center

Kalpana K Jatla, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Acknowledgements

Gerhard W Cibis, MD Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Ophthalmological Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

References
  1. Credé. Reports from the obstetrical clinic in Leipzig. Prevention of eye inflammation in the newborn. Am J Dis Child. 1971 Jan. 121(1):3-4. [Medline].

  2. Rours IG, Hammerschlag MR, Ott A, De Faber TJ, Verbrugh HA, de Groot R, et al. Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants. Pediatrics. 2008 Feb. 121(2):e321-6. [Medline].

  3. American Academy of Pediatrics. Chlamydia Trachomatis. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 255-9.

  4. American Academy of Pediatrics. Prevention of Neonatal Ophthalmia. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 827-9.

  5. Chhabra MS, Motley WW 3rd, Mortensen JE. Eikenella corrodens as a causative agent for neonatal conjunctivitis. J AAPOS. 2008 Oct. 12(5):524-5. [Medline].

  6. Chen CJ, Starr CE. Epidemiology of gram-negative conjunctivitis in neonatal intensive care unit patients. Am J Ophthalmol. 2008 Jun. 145(6):966-970. [Medline].

  7. American Academy of Pediatrics. Herpes Simplex. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 363-73.

  8. American Academy of Pediatrics. Gonococcal Infections. Pickering LK, Baker CJ, Kimberlin DW, Long SS eds. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2009. 305-13.

  9. Gul SS, Jamal M, Khan N. Ophthalmia neonatorum. J Coll Physicians Surg Pak. 2010 Sep. 20(9):595-8. [Medline].

  10. Zuppa AA, D'Andrea V, Catenazzi P, Scorrano A, Romagnoli C. Ophthalmia neonatorum: what kind of prophylaxis?. J Matern Fetal Neonatal Med. 2011 Jun. 24(6):769-73. [Medline].

  11. Pediatric Conjunctivitis. Wright, Kenneth and Strube, Yi Ning. Pediatric Ophthalmology and Strabismus. Third. New York, NY: Oxford University Press; 2012. 633-636.

  12. Yip PP, Chan WH, Yip KT, Que TL, Kwong NS, Ho CK. The use of polymerase chain reaction assay versus conventional methods in detecting neonatal chlamydial conjunctivitis. J Pediatr Ophthalmol Strabismus. 2008 Jul-Aug. 45(4):234-9. [Medline].

  13. Gichuhi S, Bosire R, Mbori-Ngacha D, Gichuhi C, Wamalwa D, Maleche-Obimbo E, et al. Risk factors for neonatal conjunctivitis in babies of HIV-1 infected mothers. Ophthalmic Epidemiol. 2009 Nov-Dec. 16(6):337-45. [Medline].

  14. Prevention of Neonatal Ophthalmia. Pickering LK, ed. American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th Edition. Elk Grove Village, IL:

  15. McDonald M, Hardten D, Mah F, O’Brien T, Rapuano C, Schanzlin D, et al. Management of Epithelial Herpetic Keratitis: An Evidence-Based Algorithm. Optometric Management. Available at http://www.optometricmanagement.com/content/bl/2/b-l_treament-finalnb.pdf. Nov 11, 2012;

 
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Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).
Cloudy cornea without ulcer in neonatal gonococcal conjunctivitis.
 
 
 
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