SAMPLE ON CALL PROBLEM FROM
8th Edition GOMELLA’S NEONATOLOGY
Chapter 58
On Call Problem: Eye Discharge and Conjunctivitis
I. Problem. A purulent eye discharge is noted in a 3-day-old infant. Eye discharge in a neonate is usually caused by neonatal conjunctivitis (also known as ophthalmia neonatorum) or congenital nasolacrimal duct obstruction (CNLDO or congenital dacryostenosis). Neonatal conjunctivitis (conjunctivitis occurring within the first 4 weeks of life) is an inflammation of the surface or covering of the eye that presents with eye discharge and hyperemia. It is the most common ocular disease in neonates. Etiology is chemical, bacterial, or viral. Most infections are acquired during vaginal delivery, but ascending infection can occur. In the United States, the incidence of infectious conjunctivitis is 1% to 2%, and in the world, it is 0.9% to 21%. Neonates with conjunctivitis require a thorough clinical and appropriate laboratory evaluation so appropriate treatment can be started as soon as possible if necessary. CNLDO is a membranous obstruction at the valve of Hasner, which is at the distal end of the nasolacrimal duct. Incidence is 6% to 20% in infants (studies show higher incidence in preterm infants when compared to full-term infants). The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.
II. Immediate questions
A. How old is the infant? Age may be helpful in determining the cause of eye discharge, noting that bacterial infections can occur anytime.
1. First day of life. Conjunctivitis is most often due to ocular prophylaxis secondary to medications such as silver nitrate drops, tetracycline, erythromycin, gentamicin, povidone iodine solution, and chloramphenicol.
2. 2 to 5 days old. Conjunctivitis is most often due to Neisseria gonorrhoeae (but can present earlier with premature rupture of membranes).
3. 5 to 12 days old. Conjunctivitis is most often due to Chlamydia trachomatis. It is usually seen during this time and can present as late as the second or third week.
4. 5 to 14 days old. Conjunctivitis is often due to other bacterial microbes. This includes pathogens from the skin, respiratory, gastrointestinal, or vaginal tract. See Table 58–3.
5. 5 to 28 days old. Pseudomonas aeruginosa infections are typical during this time.
6. 6 to 14 days old. Conjunctivitis can be due to herpes simplex virus (HSV).
7. 2 weeks old. CNLDO usually manifests at 2 weeks of age but can sometimes be seen in the first few days to the first few weeks after birth.
B. Is the discharge unilateral or bilateral? Typical symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye.
1. Unilateral conjunctivitis is most often seen with Staphylococcus aureus, P aeruginosa, HSV, and adenovirus.
2. Bilateral conjunctivitis is seen with infection caused by N gonorrhoeae or by the use of ocular prophylaxis.
3. Unilateral, then bilateral. Chlamydia usually develops in 1 eye but affects the other after 2 to 7 days. Lacrimal duct obstruction usually causes unilateral discharge, but up to 20% of infants have bilateral obstruction.
C. What are the characteristics of the discharge (eg, purulent, serous, greenish)?
1. Purulent discharge: More common with bacterial infection. Gonorrhea has a classic profuse purulent discharge.
2. Serous discharge: More common with a viral infection.
3. Greenish discharge: More characteristic of P aeruginosa.
4. Serosanguinous (light/pale red) discharge: Watery with a mixture of serum and blood can be seen with herpes conjunctivitis. Nonpurulent discharge can also be seen with herpes.
5. Watery early, purulent later (may be blood stained): Chlamydial infection.
6. Watery tears or mucus or yellow discharge in eye: CLNLDO can cause watery tears in the corner of the eye or tears draining from the eyelid down the cheek. It can also cause mucus or yellowish discharge in the eye.
D. Did the infant receive eye prophylaxis, and was it properly given? Ocular prophylaxis against gonococcal ophthalmia neonatorum is used to prevent gonorrheal infection (prevent blindness), and certain prophylactic agents (silver nitrate, povidone-iodine, and erythromycin) prevent nongonococcal and nonchlamydial conjunctivitis during the first 2 weeks of life. The majority of medical groups recommend prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum (Table 58–1). Various conjunctivitis prophylactic regimens are presented in Table 58–2. Infants can still get gonococcal conjunctivitis with prophylaxis, but the risk drops from 50% to 2%. Gonorrheal ophthalmia neonatorum prophylaxis is mandatory in the United States but may not be in other countries (eg, Denmark, Norway, Sweden, Great Britian, Belgium, Australia, The Netherlands). A reevaluation of the mandatory prophylaxis is being considered by the American Academy of Pediatrics (AAP) because of improved prenatal screening, testing at the time of delivery, and maternal treatment to prevent exposure to the neonate, especially in areas where the maternal infection is low. There is concern that some strains of gonorrhea have shown resistance to erythromycin. (See Table 58-1 and 58-2 at end of chapter)
1. Proper ocular administration technique is as follows: Give shortly after birth or within 1 hour of birth (to facilitate parent–infant bonding), whether cesarean or vaginal delivery.
a. For the term infant, wipe each eyelid with sterile cotton or gauze; instill the prophylactic agent (single-dose tubes or ampules preferred, 1-cm ribbon of ointment or 2 drops of solution) in each of the lower conjunctival sacs. Massage the eyelids gently to spread the agent. Wipe away any excess ointment after 1 minute. Do not irrigate or flush the eyes.
b. For the very premature infant with fused eyes, apply the prophylactic agent without separating the eyelids.
2. Agents used for prophylaxis: 0.5% erythromycin ophthalmic ointment, 2.5% povidone-iodine solution, 1% silver nitrate solution, and 1% tetracycline ophthalmic ointment.
a. 0.5% erythromycin ophthalmic ointment. A 1-cm ribbon is given in each eye. AAP, Centers for Disease Control and Prevention (CDC), and US Preventive Services Task Force (USPSTF) recommend only erythromycin ophthalmic ointment for prophylaxis, and it is the only approved agent in the United States. It causes less chemical conjunctivitis than other agents such as silver nitrate. There is some concern for N gonorrhoeae strains being resistant to erythromycin.
b. 1% silver nitrate solution. This is recommended over erythromycin if the patient population has a high number of penicillinase-producing N gonorrhoeae. It is highly irritating and frequently causes a chemical conjunctivitis (see later in chapter). It is not available in the United States but is used elsewhere. The World Health Organization (WHO) recommends 2 drops in each eye.
c. 1% tetracycline ophthalmic ointment is as effective as silver nitrate but is not available in the United States.
d. 2.5% povidone-iodine ophthalmic solution (water based; do not use alcohol-based solution) is widely available, low cost, and effective. It is used in developing countries and is not available in the United States. Some data suggest that povidone-iodine is more effective against C trachomatis than silver nitrate or erythromycin. There are 3 doses available (5%, 2.5%, and 1.25%); 5% is used for preoperative use. The 2.5% solution is most commonly used. Note: Use the ophthalmic solution and not the detergent version of povidone-iodine, which can damage the cornea.
e. Other topical agents that have been used when erythromycin is not available. Recommended backup agents per the AAP Red Book include the following:
i. Use first: Azithromycin ophthalmic solution 1%; 1 to 2 drops are placed in each conjunctival sac. Note this is not an ointment but a solution, so care must be used when placing these drops. CDC recommendations for this medication: 2 people are required to administer this medication. One person holds the lids open, while the other instills the drops.
ii. Use second: Either gentamicin ophthalmic ointment 0.3% or tobramycin ophthalmic ointment 3%.
iii. Use last: Ciprofloxacin ophthalmic ointment 0.3% is generally not recommended because of high gonococcal resistance.
f. Fatty acid–based formulas (monocaprin and myristoleic acid), which are bactericidal against virulent bacteria and effective against S aureus, are being studied for prevention of ophthalmia neonatorum.
3. Society and organization recommendations for ophthalmic neonatorum prophylaxis can be found in Table 58–1 at end of chapter.
E. Does the mother have a history of sexually transmitted infections? Infants who pass through the birth canal of an infected mother with gonorrhea or chlamydia have an increased conjunctivitis risk. Neonatal conjunctivitis is frequently diagnosed in infants born to human immunodeficiency virus (HIV)-infected mothers.
F. Is the infant at high risk?
1. Conjunctivitis. Neonates are at increased risk for conjunctivitis and more serious cases of conjunctivitis because of decreased tear production, lack of immunoglobulin A (IgA) in tears, decreased immune function, absence of lymphoid tissue of the conjunctiva, and decreased lysozyme activity. Risk factors may include mode of delivery, exposure of the infant to infectious organisms, no or inadequate prophylaxis after birth, ocular trauma/local eye injury during delivery, poor hygienic conditions, premature rupture of membranes, prolonged delivery, prematurity, mechanical ventilation, increased birthweight, history of midwife interference, HIV-infected mother, poor prenatal care, documented or suspected sexually transmitted infection, infection after delivery from direct contact from health care worker, or aerosolization. Performing red reflex examinations increases the rate of neonatal conjunctivitis.
2. Congenital nasolacrimal duct obstruction. Neonates are at an increased risk for CNLDO if they have Down syndrome, Goldenhar sequence, clefting syndromes, any midline facial anomaly, hemifacial microsomia, or craniosynostosis.
G. Is the infant low birthweight and low gestational age? An infant with conjunctivitis who has a low birthweight and low gestational age has a higher risk of having a conjunctivitis caused by a gram-negative organism (Klebsiella spp., Escherichia coli, Serratia marcescens, P aeruginosa, and Enterobacter spp.). Premature infants have an increased risk of CNLDO.
III. Differential diagnosis. As noted, eye discharge in the neonate most commonly is caused by conjunctivitis (chemical/inflammatory, bacterial, or viral) or is due to an obstruction (CNLDO). Other less common diagnoses that may cause an eye discharge in an infant are foreign body, orbital or preseptal cellulitis, entropion, trichiasis, eye trauma (corneal abrasion following delivery), dacryocystitis, infectious keratitis, subconjunctival hemorrhage (breakage of vessels during delivery), vitreous hemorrhage (associated with thrombocytopenia and polycythemia), congenital anomalies of the nasolacrimal system, corneal epithelial disease, neonatal abstinence syndrome (lacrimation), and congenital glaucoma. Common causes of infectious and noninfectious conjunctivitis can be found in Table 58–3 (See end of Chapter)
A. Chemical/inflammatory conjunctivitis. Usually secondary to silver nitrate ocular drops (causes a transient chemical conjunctivitis in 50%–90% of infants) and is the most common cause of conjunctivitis in underdeveloped countries. The incidence of chemical/inflammatory conjunctivitis has decreased in the United States since silver nitrate drops are no longer being used. Chemical conjunctivitis can occur from all the other prophylactic ocular antibiotics but less often. It is a nonpurulent inflammation of the eye with a watery discharge, conjunctival injection, and swelling within several hours of instilling the medication. The conjunctivitis shows a maximum inflammatory response around 48 hours and usually clears by the third or fourth day.
B. Infectious conjunctivitis. (See Table 58–3 at end of chapter.) Infectious conjunctivitis in the newborn is caused by either a bacteria or virus.
1. Mechanisms of infection
a. Infections acquired through an infected maternal genital tract during birth are typically N gonorrhoeae, C trachomatis, group B streptococci, or HSV. They tend to reflect sexually transmitted infections in the community. Any bacteria that are normally present in the vagina (not sexually transmitted) can also cause neonatal conjunctivitis.
b. Cesarean section can be associated with ascending infections through ruptured or intact amniotic membranes (transplacental or transmembrane transmission). Risk factors include amniotic fluid leak, vaginal examinations, and use of internal monitors.
c. Postnatally acquired infections from organisms that are present in the environment (normal skin flora or nasopharyngeal flora). Infection can occur through direct contact, by contamination of parent’s or caregiver’s hands or mouth, or respiratory tract spread. Examples are S aureus (coagulase negative most common in one study), Staphylococcus epidermidis, Streptococcus spp., Pseudomonas spp., Serratia spp., Klebsiella spp., and Enterococcus spp. Pseudomonas infections are more typical in hospitalized preemies beyond 5 days of birth.
2. Chlamydial (inclusion) conjunctivitis. Most common cause of ophthalmia neonatorum transmitted from the mother and develops in 20% to 50% of infants delivered vaginally to infected untreated mothers. Topical prophylaxis with erythromycin does not prevent the incidence of chlamydial ophthalmia neonatorum. Prophylaxis does not eradicate nasopharyngeal colonization or pneumonia. Infected eyes have a mucopurulent discharge, ocular congestion, and eyelid swelling; membranes form on the palpebral conjunctiva, and there is no follicular response. Infection can be unilateral or bilateral and usually starts out as a watery discharge that becomes purulent and copious later. Corneal opacification, chemosis (thickened conjunctivae), and pseudomembranes may be present. Pneumonia is present in 10% to 20% of infants with chlamydial conjunctivitis. Otitis, pharyngeal, and rectal colonization can occur. Repeated and chronic infections of C trachomatis can cause trachoma (rare in the United States), which is a chronic follicular keratoconjunctivitis that causes scarring and neovascularization of the cornea that can result in blindness.
3. Gonococcal conjunctivitis. Second most commonly reported communicable disease and is the most feared cause of neonatal conjunctivitis. Approximately 28% of infants born to women with gonorrheal disease in the United States will develop gonococcal ophthalmia neonatorum. It accounts for <1% of neonatal ophthalmia in the United States and is most commonly transmitted from the mother during vaginal birth. The transmission rate from an infected mother to her newborn is up to 50%. Ocular manifestations tend to occur 3 to 5 days after birth with abrupt onset. Usually bilateral, the eyes are very red (hyperacute conjunctivitis) with a thick, purulent drainage and swelling. The lid has chemosis (edema), and a conjunctival membrane may be present. This is an emergency because, left untreated, it can cause a corneal ulcer and perforation within hours. The incidence is low because of prophylactic ocular treatment immediately after birth. Infants can manifest systemic manifestations, including sepsis, meningitis, arthritis, vaginitis, and urethritis.
4. Pseudomonas conjunctivitis. A nosocomial infection that used to be rare but is becoming more common in nurseries. It presents with a purulent discharge, eyelid edema and erythema, and pannus formation. It can lead to a devastating and rapid corneal ulceration and perforation, blindness, endophthalmitis, and death. The organism thrives in moisture-filled environments such as respiratory equipment, and infection occurs most often in hospitalized premature infants or those with depressed immunity. It can be responsible for an epidemic conjunctivitis in premature infants. Infants with Pseudomonas conjunctivitis can have systemic complications (sepsis/meningitis).
5. Herpes simplex keratoconjunctivitis. There are 3 different types of presentation of herpes in the neonate. The one that will be discussed here is disease localized to the skin, eyes, or mouth (SEM disease). HSV type 2 (HSV-2) can cause unilateral or bilateral conjunctivitis (especially keratoconjunctivitis), optic neuritis, chorioretinitis, cataracts encephalitis, and permanent vision impairment and is the most frequent viral cause of conjunctivitis. The conjunctivitis can be superficial or may involve the deeper layers of the cornea; vesicles may appear on the nearby skin (80% of infants with SEM have skin vesicles). The infants can have lid edema, conjunctival injection, and a watery nonpurulent discharge. A conjunctival membrane may be present. Most of these infections are secondary to HSV-2 sexually transmitted infection (maternal genital tract ascending infection, through the birth canal, or by transplacental mechanisms); 15% to 20% are caused by HSV-1. Suspect herpes if the conjunctivitis is not responding to antibiotic therapy. Most neonatal HSV-1 infections are related to contact with someone with an active infection (fever blister or cold sore) in the perinatal period.
6. Viral causes (other than herpes). Infection usually occurs through direct contact, through contamination of the hands, or via respiratory tract spread. These are usually associated with other symptoms of respiratory tract disease due to adenovirus (most common), Enterovirus, or Parechovirus. There is usually redness, and it is more commonly unilateral. Infants with adenovirus can have petechial hemorrhages. The discharge is usually mild and watery and is rarely purulent. Lymphadenopathy and preauricular adenopathy can be seen in approximately 50% of cases. Epidemic keratoconjunctivitis from adenovirus can occur by direct contact or from equipment during an eye examination. The CDC site states that Zika virus can cause a conjunctivitis when an infant acquires the infection perinatally (from women who become infected within 2 weeks of delivery). Perinatal transmission of chikungunya virus can also cause conjunctivitis.
7. Other bacterial infections (nongonococcal, nonchlamydial). (See Table 58–3.) Conjunctivitis can be caused by other microbial agents (not listed earlier), and these usually present as a milder form of conjunctivitis. There may be conjunctival injection, chemosis, and a discharge. Infections caused by Haemophilus spp. and Streptococcus pneumoniae are associated with dacryocystitis (inflammation of the nasolacrimal sac). Staphylococcal conjunctivitis is usually a nosocomial infection. It is the most frequent isolate but may not be a cause of conjunctivitis in infants who are colonized and can cause mild conjunctival hyperemia. Methicillin-resistant S aureus conjunctivitis can also occur and has been associated with nurseries and NICUs.
C. Congenital nasolacrimal duct obstruction (dacryostenosis) occurs in approximately 5% to 20% of infants. The nasolacrimal duct may fail to canalize completely at birth, and the obstruction is usually at the nasal end of the duct (distal nasolacrimal duct). It is usually unilateral. The symptoms are persistent tearing and a mucoid discharge in the inner corner of the eye. One in 5 infants may have transient discharge (watery and sticky, particularly after sleep) due to a delay in the normal development and opening of the tear duct that resolves spontaneously. CNLDO is the most common of the lacrimal duct anomalies in congenital rubella syndrome. Dacryocystitis is a secondary infection in the lacrimal sac.
IV. Database
A. Physical examination
1. Ophthalmic examination. Examine both eyes/eyelids for swelling and edema, and check the conjunctiva for injection (congestion of blood vessels) and chemosis (conjunctival swelling). A purulent discharge, edema, and erythema of the lids and injection of the conjunctiva are suggestive of bacterial conjunctivitis. Check for ulcerations and the presence of a red reflex.
2. Perform a complete physical examination to rule out signs of respiratory or systemic infection. Evaluate for any adenopathy.
B. Laboratory studies
1. Gram-stained smear of the exudate discharge to check for white blood cells (WBCs) (a sign of infection) and bacteria (to identify the organism). A sample of the discharge should also be submitted for culture and sensitivity testing (chocolate agar and/or Thayer-Martin agar for N gonorrhoeae and blood agar for other bacteria). Typical findings on Gram stain:
a. N gonorrhoeae conjunctivitis. Gram-negative intracellular diplococci (kidney bean shaped) and increased WBCs (neutrophils). Note: A presumptive diagnosis can be made based on the Gram stain, but remember that other nonpathogenic Neisseria species and Moraxella catarrhalis can look like N gonorrhoeae on Gram stain, so it is best to support the diagnosis with a culture.
b. S aureus conjunctivitis. Gram-positive cocci in clusters and WBCs.
c. P aeruginosa conjunctivitis. Gram-negative bacilli and WBCs.
d. Conjunctivitis caused by Haemophilus spp. Gram-negative coccoid rods.
e. Streptococcal or enterococci. Streptococci are gram-positive spherical cocci, and enterococci are gram-positive lancet-shaped encapsulated diplococci.
f. Other gram-positive organisms. S pneumoniae, Streptococcus viridans, S epidermidis, group A and B streptococci, and Corynebacterium species.
g. Other gram-negative organisms. E coli, Klebsiella pneumoniae, S marcescens, Proteus, Enterobacter, H influenzae, Acinetobacter, P aeruginosa, Neisseria cinerea, M catarrhalis, Eikenella corrodens, and Stenotrophomonas maltophilia.
h. Herpes simplex. See lymphocytes, plasma cells, and multinucleated giant cells.
i. C trachomatis. Difficult to stain but classified as gram negative, typically coccoid or rod shaped bacteria. Neutrophils, lymphocytes, and plasma cells.
j. Chemical conjunctivitis. Neutrophils and lymphocytes (occasionally).
k. CNLDO. The Gram stain is negative, or there is normal conjunctival flora unless there is a secondary infection.
2. If a chlamydial infection is suspected, methods to diagnose chlamydia ophthalmia include:
a. Culture identification of the organism (gold standard) by a conjunctival swab specimen with 100% specificity and sensitivity. A result can be obtained after 48 to 72 hours.
b. Nonculture testing
i. Antigen detection methods include direct fluorescent antibody (DFA) and enzyme immunoassay (EIA) tests. DFA is the only US Food and Drug Administration (FDA)-approved nonculture test for chlamydia conjunctivitis in the neonate. An example of one such platform is the commercially available Pathfinder Chlamydia DFA (Bio-Rad Laboratories, Hercules, CA).
ii. Nucleic acid amplification tests, which use a method of amplifying C trachomatis DNA or RNA sequences. Nucleic acid amplification tests (NAATs) are not FDA approved for use in conjunctivitis in infants but can be used if available through a Clinical Laboratory Improvement Amendments–certified laboratory. Some believe that NAAT has higher sensitivity and specificity than the DFA assays and may actually outperform culture results.
c. To obtain the swab specimen, use a Dacron-tipped swab or swab from the manufacturer (do not use calcium alginate or wood shafted swabs) and evert the eyelid; then swab the everted eyelid to obtain conjunctival cells. The exudate is not adequate for the test.
3. If herpes is suspected. Historically a histologic exam of lesions for multinucleated giant cells and eosinophilic intranuclear inclusions was performed (Tzanck smear), but is no longer recommended due to low sensitivity. Recommended test is the cell culture of swab specimens (surface and other), skin vesicles, and cerebrospinal fluid (CSF). HSV polymerase chain reaction (PCR) assay can be done on all the specimens including whole blood sample (a positive result does not mean disseminated disease) but has not been studied in neonates. Rapid diagnostic techniques such as DFA and EIA are available but less sensitive than cultures. A rapid culture test, ELVIS ID HSV test system (Quidel Corporation, San Diego, CA), is available.
4. In gonococcal infection, cell culture is the most widely used test for nongenital sites. NAATs are not FDA approved for N gonorrhoeae testing on nongenital sites.
5. Pseudomonas infection. Suspect based on Gram stain and send culture of the exudate.
C. Imaging and other studies. Imaging tests usually do not have a role in the workup of conjunctivitis but neuroimaging may be done in herpes conjunctivitis.
1. Blot test for nasolacrimal duct obstruction. Apply gentle digital pressure over the lacrimal sac. If there is moisture, it indicates an obstruction. If there is a mucopurulent reflux (positive blot test) from the punctum, this suggests a complete obstruction.
2. Fluorescein dye disappearance test. Best test to rule out CNLDO. Instill 1 drop of 0.5% proparacaine followed by 1 drop of 2% fluorescein/moistened fluorescein strip into the lower conjunctiva of each eye. Wipe away any excess dye. After 5 to 10 minutes, evaluate if any dye is still present. If there is significant dye present in the eye and failure of the dye to appear in the nose after 10 to 15 minutes, then an obstruction may exist. If the dye disappears, then there is no obstruction. Alternatively, dim the room and use a cobalt blue light or Burton lamp to see if the dye is still present.
3. Slit lamp examination with fluorescein staining by an ophthalmologist. Can help differentiate viral versus bacterial conjunctivitis. With viral one can see conjunctival follicles, with bacterial one can see papillae. One will see dendritic keratitis with HSV keratitis.
4. Tests for viral conjunctivitis. Viral cell culture with immunofluorescence assay and PCR. Rapid antigen testing (Adeno Plus, Rapid Pathogen Screening, Inc.) is available for adenovirus.
V. Plan. Complications (perforation of the cornea, blindness, Chlamydia pneumonia, sepsis, meningitis) can be severe, so it is important to treat as soon as possible. Do not wait for the culture results to treat the infant. Send the culture, and based on the Gram stain, start empirical treatment,
A. Important facts in the management of conjunctivitis
1. Infection can spread easily from one eye to another or to other people by touching the eye or drainage. Proper and frequent hand washing and wearing gloves are essential. Isolation is recommended for gonococcal, herpes, and Pseudomonas conjunctivitis. See Appendix F for specific isolation guidelines.
2. Drainage is contagious for 24 to 48 hours after beginning treatment.
3. Irrigate eye with sterile isotonic saline to remove accumulated purulent drainage.
4. Systemic treatment is required for gonococcal, Chlamydia, Pseudomonas, and herpetic conjunctivitis. Some recommend systemic treatment for H influenzae conjunctivitis since it is often associated with otitis media or other severe infections such as sepsis and meningitis. Topical and systemic treatment is recommended for Pseudomonas and herpes infection.
5. Avoid eye patching.
6. Consultation with a pediatric ophthalmologist or pediatric infectious disease specialist should be considered.
7. Evaluate for signs of systemic disease. Infants with conjunctivitis are at risk for secondary infections such as sepsis, meningitis, and pneumonia.
8. Follow daily for signs of improvement or worsening.
9. Breast milk/colostrum to treat conjunctivitis. Colostrum and breast milk contain antimicrobial and anti-inflammatory properties and have been used to treat conjunctivitis or mucopurulent discharge from nasolacrimal duct obstruction. Colostrum is more effective than mature breast milk because it contains leukocytes and has higher concentrations of antibodies, especially IgA. Studies suggest that the use of breast milk or colostrum is safe, has no side effects, and may help as a treatment for blocked tear ducts and that the use of colostrum may be effective against certain type of infections. However, because evidence is limited and studies are conflicting, this treatment is not recommended. Preventive effects of colostrum (2 drops in each eye) against neonatal conjunctivitis have been documented when compared to no prophylaxis.
B. Chemical conjunctivitis. Observation only is needed because this usually resolves within 2 to 4 days. Lubrication with artificial tears (4 times a day) may be helpful.
C. Gonococcal conjunctivitis. This is considered an emergency, as it can result in perforation of the globe, corneal scarring, and blindness. Because of the high prevalence of penicillin-resistant N gonorrhoeae, the treatment is not penicillin but a third-generation cephalosporin (eg, ceftriaxone). Note: Gonococcal conjunctivitis can occur even with appropriate eye prophylaxis in infants delivered to mothers with positive maternal gonococcal infection.
1. Infants with evidence of gonococcal conjunctivitis, scalp abscess, or disseminated infection need to be hospitalized.
2. Isolate the infant during the first 24 hours of parenteral antibiotic therapy. Both mother and partner need full medical examinations and treatment for N gonorrhoeae. Mother cannot visit the baby, breast feed, or room-in until she receives 24 hours of antibiotics.
3. Evaluate for disseminated disease if the infant has gonococcal ophthalmia (arthritis, meningitis, sepsis, scalp abscess caused by scalp electrodes from fetal monitoring). Cultures should include blood, eye discharge, CSF, joint aspirate, and any other sites, as noted earlier. Conjunctival exudates need to be cultured for N gonorrhoeae and tested for antibiotic susceptibility.
4. Tests for concomitant infection with C trachomatis, congenital syphilis, and HIV. The mother and her sexual partner should also be evaluated and presumptively treated for gonorrhea. Check maternal hepatitis B surface antigen results. Do not treat empirically for chlamydia unless the test comes back positive.
5. Parenteral antibiotics. Ceftriaxone is the preferred antibiotic treatment because of the high frequency of penicillin-resistant N gonorrhoeae. Ceftriaxone is not recommended in a neonate with hyperbilirubinemia or in a neonate receiving or planning on receiving calcium-containing intravenous (IV) fluids. Ceftriaxone can displace bilirubin from binding to serum albumin, possibly causing bilirubin encephalopathy. Cefotaxime is recommended in any infant with hyperbilirubinemia and in infants on calcium-containing IV fluids.
6. For uncomplicated gonococcal conjunctivitis (without dissemination), administer a single dose of ceftriaxone 25 to 50 mg/kg IV or intramuscularly (IM) (up to a maximum of 125 mg). WHO recommends 1 of the following: ceftriaxone (50 mg/kg IM single dose [maximum 150 mg]), kanamycin (25 mg/kg IM single dose [maximum 756 mg]), or spectinomycin (25 mg/kg IM single dose [maximum 75 mg]).
7. For gonococcal conjunctivitis with dissemination (arthritis, septicemia) and scalp abscess, ceftriaxone 25 to 50 mg/kg IV or IM may be given once every day for 7 days. An alternative therapy is cefotaxime (recommended for hyperbilirubinemic infants or infants receiving calcium-containing IV fluids) at 25 mg/kg every 12 hours, given IV or IM for 7 days. If meningitis is present, treatment should be given for a total of 10 to 14 days.
8. Healthy infants (no conjunctivitis) born to mothers with untreated or inadequately treated gonococcal infection. These infants are treated with systemic antibiotics because gonococcal ophthalmia or disseminated infection can occur. A single dose of ceftriaxone (25–50 mg/kg IV or IM; not to exceed 125 mg) is given. Topical antimicrobial therapy is not necessary if systemic therapy has been given.
9. Irrigate the eyes with sterile isotonic saline (normal saline) solution immediately and at frequent intervals (every 1–2 hours) to remove mucopurulent discharge until clear. Topical antibiotics are not necessary when systemic antibiotics are used and are only recommended when a corneal ulcer is present. Use topical atropine if there is corneal involvement.
10. Pediatric ophthalmologic consultation is usually requested because gonococcal ophthalmia can lead to corneal perforation and blindness. Infectious disease consultation is usually requested also to help manage the infant.
D. Chlamydial conjunctivitis. Evaluate for systemic disease (pneumonia, otitis, pharyngeal and rectal colonization). Pneumonia has been reported in 20% of infants with chlamydial conjunctivitis.
1. Recommended neonatal prophylaxis does not prevent neonatal chlamydial conjunctivitis, extraocular infection, or nasopharyngeal colonization.
2. Topical treatment with antibiotics is ineffective and unnecessary when systemic therapy is given, but some institutions use erythromycin drops (4 times a day).
3. Oral erythromycin base or ethylsuccinate, 50 mg/kg/d, in 4 divided doses for 14 days by mouth, is recommended. Azithromycin suspension (20 mg/kg/d for 3 days) is an alternative regimen. A second course of erythromycin is sometimes required because approximately 20% of cases recur after therapy because erythromycin is only about 80% effective. Infantile hypertrophic pyloric stenosis (IHPS) has been seen in infants <6 weeks="" old="" especially="" 2="" treated="" with="" erythromycin="" it="" has="" been="" seen="" azithromycin="" but="" the="" risk="" is="" unknown="" these="" infants="" should="" be="" followed="" and="" parents="" counseled="" about="" signs="" of="" ihps="" aap="" still="" recommends="" because="" other="" treatments="" have="" not="" well="" studied="" who="" 20="" mg="" kg="" d="" orally="" 1="" dose="" daily="" for="" 3="" days="" over="" p="">
4. Infants born to mothers with untreated chlamydia are at high risk for infection. Prophylactic antibiotic treatment is not indicated. Monitor for infection. If adequate follow-up is not possible, treatment should be considered.
5. Treat the mother and sexual partner if the infant has C trachomatis infection.
E. Pseudomonas conjunctivitis
1. Isolate the patient and implement standard precautions unless infection is resistant, in which case contact precautions are indicated.
2. Evaluate for systemic disease because superficial infection can progress rapidly to serious systemic infection (sepsis, meningitis). Infants with low birthweight and lower gestational age have an increased risk for systemic disease. Pseudomonas infection can lead to devastating consequences: corneal ulceration and perforation, endophthalmitis, blindness, serious systemic infection, and subsequent death.
3. Parenteral therapy is recommended because Pseudomonas is a virulent organism. Use an aminoglycoside for a minimum of 10 to 14 days. Systemic therapy with an antipseudomonal β-lactam may also be indicated.
4. Topical therapy is required because systemic antibiotics have poor penetration in the eye. Treat with topical therapy for 2 weeks with an aminoglycoside, such as gentamicin ophthalmic ointment or tobramycin ophthalmic ointment/solution. Some will treat with ciprofloxacin ophthalmic ointment/solution because gentamicin and tobramycin can cause a chemical conjunctivitis. See doses in Table 58–4.(End of chapter)
5. Ophthalmology consultation is critical because the infection may be devastating. Infectious disease consult may also be helpful, especially with Pseudomonas meningitis. For Pseudomonas meningitis, careful follow-up is recommended (check for hearing loss, developmental delay, and neurologic abnormalities).
F. Herpes simplex conjunctivitis
1. Isolate the patient and implement contact precautions. Infant can room-in if low risk of infection, and mother can visit and breast feed if there are no vesicular herpetic lesions in the breast area and all lesions are covered.
2. Obtain a complete set of viral cultures (PCR assays on skin and mucus have not been studied in neonates; do this in addition to the gold standard cultures). A positive culture obtained from any of the surface sites >12 to 24 hours after birth is considered positive and not intrapartum exposure contamination.
a. Obtain a surface culture from the mouth, nasopharynx, conjunctivae, and anus for HSV surface culture and HSV PCR assay (if desired). Any positive culture from any surface area >12 to 24 hours after birth indicates viral replication and is suggestive of an infection in the infant and not contamination by intrapartum exposure.
b. Skin vesicle (if present) culture for HSV and PCR assay.
c. Cerebrospinal fluid and whole blood culture for HSV and PCR assay, as clinical findings may be absent in CSF disease early on.
d. Whole blood sample for serum alanine aminotransferase. Can be elevated in HSV hepatitis.
e. Direct fluorescent antibody staining of vesicle scrapings or EIA detection of HSV antigens. These methods are specific but less sensitive than a culture.
3. Administer a topical therapy with ocular herpes simplex virus: 1% trifluridine solution/drops or 0.15% ganciclovir gel (both are proven to be effective) 5 times per day for 10 days (every 2 hours).
4. Parenteral acyclovir for all neonates with herpes simplex virus disease (including conjunctivitis): 60 mg/kg/d IV divided 3 times a day for a minimum of 14 days for SEM disease. If central nervous system (CNS) disease or disseminated disease is present, treat for a minimum of 21 days. (For dosage, see Chapter 155.)
5. Ophthalmologic evaluation and follow up are required for all infants with neonatal HSV disease because chorioretinitis, cataracts, and retinopathy may develop. Infectious disease consultation is also recommended.
6. Neuroimaging should be done for a baseline brain anatomy (magnetic resonance imaging is the most sensitive, but computed tomography or ultrasound is also acceptable). Neurologic follow-up is important.
7. With cerebrospinal fluid involvement, a repeat lumbar puncture (LP) needs to be done near the end of the therapy to document that CSF is negative for HSV DNA on PCR assay; if positive, another week of therapy needs to be given and another repeat LP needs to be done. Parenteral treatment should not be stopped until CSF PCR is negative.
8. Suppression therapy with oral acyclovir (300 mg/m2/dose) 3 times a day for 6 months is recommended following acute neonatal HSV disease. Adjust dose for growth. This prevents skin recurrences and improves neurodevelopmental outcomes in infants with CNS disease. Check absolute neutrophil counts at 2 and 4 weeks after starting therapy and then monthly.
G. Other bacterial infections once gonococcal, chlamydial, and Pseudomonas infections have been ruled out.
1. Local saline irrigation.
2. Topical antibiotics only are usually required. (See Table 58–4.) For gram-positive organisms: bacitracin or erythromycin. For gram-negative organisms: gentamicin, tobramycin, or ciprofloxacin ointment or solution. Ointments are preferred over eye drops for neonates because they have reduced washout effect.
a. Ophthalmic ointment: 0.5- to 1-cm ribbon in each eye every 6 hours for 7 to 14 days.
b. Ophthalmic solution: 1 to 2 drops into each eye every 4 hours for 7 to 14 days.
3. H influenzae infection may require further evaluation of the infant (rule out sepsis, meningitis, and other infections if indicated), and systemic antibiotics may be necessary. Topical conjunctivitis can be treated with any fluoroquinolone topical antibiotic.
4. Methicillin-resistant S aureus conjunctivitis. Treatment depends on the clinical situation; some do not need to be treated. Topical chloramphenicol eye drops and fortified vancomycin drops can be compounded under the direction of an ophthalmologist. See Chapter 141.
5. For gram-negative conjunctivitis in premature low birthweight infants and increasing antibiotic resistance (especially noted among the β-lactam antibiotics), third- and fourth-generation antibiotics are recommended.
6. Viral infections other than herpes simplex conjunctivitis. Treatment of viral conjunctivitis is mainly supportive (artificial tears, cool compresses). It usually resolves without specific treatment. One study found that conjunctival irrigation with 2.5% povidone-iodine was effective for the treatment of adenoviral conjunctivitis (“pink eye”) in infants and reduced the spread of infection.
H. Congenital nasolacrimal duct obstruction is the most common cause of persistent tearing and discharge in infants. Treatment can involve nonsurgical or surgical methods. Nonsurgical treatment consists of observation or digital massage (Crigler massage). Surgical treatment consists of probing the nasolacrimal duct to open the membranous obstruction, nasolacrimal duct stent insertion, balloon catheter dilation, or dacryocystorhinostomy.
1. Observation. Most cases clear spontaneously without treatment. Studies show varying results (66% to 88% to 96% resolution in 6 to 10 months to 1 year). Some physicians will treat with topical antibiotic eye drops to treat the discharge or mattering around the eye.
2. Digital (Crigler) massage. Massaging the inside corner of the eye over the lacrimal sac, in a downward motion with expression toward the nose, can exert hydrostatic pressure on the lower end of the lacrimal duct and may help to open any obstruction and establish patency. The massage method involves 5 to 10 strokes 4 times a day.
3. Nasolacrimal probing. If the problem does not resolve and symptoms persist (usually after 6 months), the infant should be evaluated by an ophthalmologist. Probing of the duct is usually indicated. It can be done as an office procedure or under general anesthesia. Probing will not work if the duct is swollen due to infection or if the obstruction is caused by a bony protrusion of the inferior turbinate. Probing is not without risk of complications, which can include creation of a false passage, injury to the nasolacrimal duct, bleeding, aspiration, and laryngospasm. There is controversy as to when this should be done (early or later). A Cochrane group performed a review to see if immediate probing versus delayed probing resulted in more treatment success. Results noted that the effects of immediate versus deferred probing are uncertain but found that children who had unilateral CNLDO and immediate office probing had a higher success of treatment compared to deferred probing.
4. Nasolacrimal duct stent insertion, balloon catheter tear duct dilation, and dacryocystorhinostomy are reserved for those cases that have failed other procedures.
I. Dacryocystitis. This is an infection of the lacrimal (tear) sac. It is almost always related to nasolacrimal duct obstruction. It can cause redness, swelling, and pain near the nose just below the lower lid.
1. Congenital dacryocystitis is a serious disease that can cause orbital cellulitis, brain abscess, meningitis, sepsis, and death if not treated immediately and aggressively with systemic antibiotics. Urgent ophthalmology consult is necessary.
2. Acquired dacryocystitis can be acute or chronic.
a. Acute dacryocystitis. Sudden onset of redness and edema over the lacrimal sac and may have injection of the conjunctiva and preseptal cellulitis. Orbital cellulitis can also occur, and urgent ophthalmology consultation is recommended. Treatment includes heat, systemic antibiotics, and percutaneous drainage of the abscess.
b. Chronic dacryocystitis. Infant presents with tearing and mattering. Inside the lacrimal sac is a chronic low-grade bacterial infection. Treatment includes dacryocystorhinostomy.
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