Neonatal Conjunctivitis

Epidemiology: Approximately 10% of the newborn contract conjunctivitis.

Etiology (Table 4.3): The most frequent pathogens are Chlamydia, followed by gonococci. Neonatal conjunctivitis is less frequently attributable to other bacteria such as Pseudomonas aeruginosa, Haemophilus, Staphylococcus aureus and Streptococcus pneumoniae, or to herpes simplex. The infection occurs at birth. Chlamydia infections are particularly important because they are among the most common undetected maternal genital diseases in Europe, affecting 5% of all pregnant women. Neonatal conjunctivitis sometimes occurs as a result of Crede's method of prophylaxis with silver nitrate, required by law in Europe to prevent bacterial infection.

Symptoms: Depending on the pathogen, the inflammation will manifest itselfbetween the second and fourteenth day of life (Table 4.3). The spectrum ranges from mild conjunctival irritation to life-threatening infection (especially with gonococcal infection). Conjunctivitis as a result of Crede's method of prophylaxis appears with hours but only leads to mild conjunctival irritation.

H Acute purulent conjunctivitis in the newborn (gonococcal conjunctivitis) is considered a medical emergency. The patient should be referred to an ophthalmologist for specific diagnosis.

Table 4.3 Differential diagnosis of neonatal conjunctivitis (ophthalmia neonatorum)

Cause

Onset

Findings

Cytology and

laboratory tests

Toxic (AgNÜ3: silver

Within hours

Hyperemia

Negative culture

nitrate; Crede's pro

Slight watery to

phylaxis)

mucoid discharge

Gonococci (gono-

2nd-4th day

Acute purulent

Intracellular Gram-

coccal conjunctivitis)

of life

conjunctivitis

negative diplococci;

positive culture on

blood agar and choc-

olateagar

Other bacteria (Pseu

4th-5 th day

Mucopurulent

Gram-positive or

domonas aeruginosa,

of life

conjunctivitis

Gram-negative

Staphylococcus

organisms; positive

aureus, Streptococcus

culture on blood

pneumoniae,

agar

Haemophilus)

Chlamydia (inclusion

5th-14th day

Mucopurulent

Giemsa-positive

conjunctivitis)

of life

conjunctivitis,

cytoplasmic inclu-

less frequently

sion bodies in

purulent

epithelial cells; nega-

Viscous mucus

tive culture

Herpes simplex virus

5 th-7 th day

Watery blepharo-

Multinucleated giant

of life

conjunctivitis

cells, cytoplasmic

Corneal involve-

inclusion bodies;

ment

negative culture

Systemic manifes-

tations

Diagnostic considerations: The tentative clinical diagnosis is made on the basis of the onset of the disease (Table 4.3) and the clinical syndrome. For example, gonococcal infections (gonococcal conjunctivitis) are typified by particularly severe accumulations of pus (Figs. 4.16a and b). The newborn's eyelid are tight and swollen because the pus accumulates under them. When the baby's eyes are opened, the pus can squirt out under pressure and cause dangerous conjunctivitis in the examiner's own eyes.

U The examiner should always wear eye protection in the presence of suspected gonococcal conjunctivitis to guard against infection from pus issuing from the newborn's eyes. Gonococci can penetrate the eye even in the absence of a corneal defect and lead to loss of the eye.

Gonococcal Conjunctivitis Newborn

Fig. 4.16 a Highly infectious conjuncti- b The Gram stain of the conjunctival vitis with swelling of the eyelids and smear reveals characteristic Gram-nega-

creamy purulent discharge issuing from tive intracellular diplococci (gonococci). the palpebral fissure.

Fig. 4.16 a Highly infectious conjuncti- b The Gram stain of the conjunctival vitis with swelling of the eyelids and smear reveals characteristic Gram-nega-

creamy purulent discharge issuing from tive intracellular diplococci (gonococci). the palpebral fissure.

The diagnosis should be confirmed by cytologic and microbiological studies. However, these studies often fail to yield unequivocal results, so that treatment must proceed on the basis of clinical findings.

Differential diagnosis: The onset of the disease is crucial to differential diagnosis (Table 4.3). Neonatal conjunctivitis must be distinguished from neonatal dacryocystitis. This disorder differs from the specific forms of conjunctivitis in it only becomes symptomatic two to four weeks after birth, with reddening and swelling of the region of the lacrimal sac and purulent discharge from the puncta. It can be readily distinguished from neonatal conjunctivitis because of these symptoms.

Treatment: Toxic conjunctivitis (Crede's method of prophylaxis): When the eye is regularly flushed and the eyelids cleaned, symptoms will abate spontaneously within one or two days.

Gonococcal conjunctivitis: Topical administration of broad-spectrum antibiotics (gentamicin eyedrops every hour) and systemic penicillin (penicillin G

IV 2 mill. IU daily) or cephalosporin in the presence of penicillinase-produc-ing strains.

Chlamydial conjunctivitis: Systemic erythromycin and topical erythromycin eyedrops five times daily. There is a risk of recurrence where the dosage or duration of treatment is insufficient. It is essential to examine the parents and include them in therapy.

Herpes simplex conjunctivitis: Therapy involves application of acyclovir ointment to the conjunctival sac and eyelids as herpes vesicles will usually be present there, too. Systemic acyclovir therapy is only required in severe cases.

Prophylaxis: Credé's method of prophylaxis (application of 1 % silver nitrate solution) prevents bacterial inflammation but not chlamydial or herpes infection. Prophylaxis of chlamydial infection consists of regular examination of the woman during pregnancy and treatment in appropriate cases.

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Responses

  • Lisa
    Why crede's method on eye was discarded?
    3 years ago

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