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.
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.
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. [14]
Topical antibiotics can also be considered to prevent secondary bacterial infections in cases with significant epithelial defects.
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. [15] 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. [15]
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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Severe purulent discharge and eyelid edema in a newborn with gonococcal conjunctivitis (confirmed with Gram stain and culture).
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Cloudy cornea without ulcer in neonatal gonococcal conjunctivitis.
