Neonatal conjunctivitis

Neonatal conjunctivitis is inflammation of the conjunctiva in infants < 4 weeks of age. Most cases are caused by perinatally transmitted infections (e.g., gonorrhea, chlamydia), however, rarely, neonatal conjunctivitis may result from a reaction to antimicrobial prophylaxis given at birth (aseptic neonatal conjunctivitis). Common features include conjunctival injection, swollen eyelids, and ocular discharge. Untreated infections may progress rapidly, causing blindness and systemic infection. Culture of the conjunctiva and exudate should be performed for neonates exhibiting clinical features of neonatal conjunctivitis before initiating immediate antimicrobial therapy. All patients should be monitored for signs of neonatal sepsis and specialists should be consulted early in management. Neonatal conjunctivitis is rare in high-income countries because of the implementation of comprehensive preventive measures (i.e., counseling on sexually transmitted infection prevention, antenatal screening and treatment of infections, and prophylactic antibiotics at birth).

• Prevalent in resource-limited countries: significant cause of pediatric blindness in these countries ^[4]
• Incidence in the US is approximately: ^[6]
  • Chlamydial neonatal conjunctivitis: 2.1 per 100,000 live births
  • Neonatal gonococcal conjunctivitis: 0.2 per 100,000 live births
• 30–50% of infants born to mothers with gonorrhea or chlamydia will develop neonatal conjunctivitis. ^[6]

Epidemiological data refers to the US, unless otherwise specified.

• Transmitted perinatally via exposure in utero or during vaginal delivery ^[4]
• Common pathogens include: ^[1][7]
  • Bacteria
    • Chlamydia trachomatis (most common)
    • Neisseria gonorrhoeae
    • Pseudomonas aeruginosa (common in premature infants)
    • Streptococcus pneumoniae
    • Haemophilus influenzae
  • Viruses
    • Herpes simplex virus
    • Adenovirus

• Develop within 2–28 days of birth; dependent on etiology ^[1]
• Common features include: ^[1]
  • Conjunctival injection
  • Chemosis
  • Eyelid edema
  • Ocular discharge (may be watery, blood-stained, or purulent) ^[4]
• May be accompanied by systemic symptoms depending on the causative pathogen ^[1][3][4]
  • HSV: vesicular rash, meningoencephalitis (see “HSV infection in the newborn”)
  • Pseudomonas: sepsis, meningitis
  • N. gonorrhoeae: sepsis, arthritis, meningitis (see “Disseminated gonococcal infection”)

Infants infected with C. trachomatis may present with pneumonia 3 weeks to 3 months after birth; this may be after conjunctivitis has resolved. ^[1]

• All patients: Obtain Gram stain, Giemsa stain, and culture of the conjunctiva and conjunctival exudate. ^[1][2]
• Consider the following, depending on the suspected etiology (see also “Overview of neonatal conjunctivitis”): ^[1][2][7]
  • PCR ^[1][7]
  • Viral cultures
  • Direct fluorescent antibody test ^[1]
  • Enzyme immunoassay
• Further studies may be necessary if there is suspicion for systemic infection, e.g.:
  • Diagnostics for sepsis
  • Neonatal HSV testing

Approach ^[1]

• Maintain a very low threshold for treatment initiation. ^[4][5]
• Start antimicrobial therapy for neonatal conjunctivitis based on the suspected etiology.
• Urgently consult pediatric infectious diseases and/or ophthalmology.
  • Most patients require inpatient treatment.
  • Patients with aseptic neonatal conjunctivitis and those with some forms of mild bacterial conjunctivitis can be managed as outpatients.
• Initiate contact precautions: Isolate infected neonates with their mothers away from other infants. ^[8]
• Clean the patient's eyes at least every 4–6 hours with a sterile swab soaked in saline. ^[8][9]
• Monitor for signs of neonatal sepsis (see “Disseminated gonococcal infection” and “Neonatal HSV infection”).
• If necessary, treat mothers and partners for genitourinary infections, e.g., gonorrhea, chlamydia.

Neonatal conjunctivitis is an acute medical emergency that can rapidly result in blindness and/or systemic infection.

Antimicrobial therapy for neonatal conjunctivitis

• Neonatal gonococcal conjunctivitis: third-generation cephalosporin (IV or IM)
  • Preferred: single-dose ceftriaxone (off-label) ^[1][2][3]
  • For infants receiving IV calcium: cefotaxime (off-label) ^[1][3]
• Chlamydial neonatal conjunctivitis
  • First line: oral erythromycin ^[2][3]
  • Alternative: azithromycin (off-label) ^[1]
• Pseudomonal conjunctivitis: Urgently consult infectious diseases; topical and systemic antibiotics are required. ^[1][10][11]
• Other bacterial conjunctivitis ^[8]
  • Gram-positive bacteria: topical erythromycin , tetracycline (off-label) , or bacitracin (off-label) ^[12][13]
  • Gram-negative bacteria: topical tobramycin (off-label) or ciprofloxacin (off-label) ^[12][13]
• Neonatal HSV conjunctivitis: IV acyclovir ^[1]
  • Specialists may consider adjunctive topical antivirals.
  • See also “Neonatal HSV.”

Treatment is often unsuccessful (∼ 20%) in infants with chlamydial conjunctivitis; reassess after the course of antibiotics is complete, as a second course may be required. ^[1]

Avoid ceftriaxone in neonates who are premature, have hyperbilirubinemia, or require calcium-containing IV solutions (e.g., parenteral nutrition). ^[3]

Closely monitor infants aged ≤ 6 weeks for hypertrophic pyloric stenosis after oral erythromycin use. ^[3]

• Endophthalmitis
• Corneal perforation
• Blindness
• Disseminated infection (meningitis, sepsis)

We list the most important complications. The selection is not exhaustive.

Prenatal measures ^[1][3][4]

• Offer patients and their partners counseling on sexually transmitted infection prevention.
• Provide antenatal screening for C. trachomatis and N. gonorrhea.
  • First trimester: Screen individuals with risk factors for STIs; consider screening all individuals. ^[1]
  • Third trimester: Repeat screening for individuals with risk factors for STIs (see also “Indications for third-trimester STI screening”). ^[1]
• Treat the mother and any partners for confirmed infections, e.g.: ^[3]
  • Gonorrhea: IM third-generation cephalosporin
  • Chlamydial genitourinary infections: oral azithromycin
  • HSV infections: oral acyclovir
• Rescreen mothers treated for bacterial sexually transmitted infections.
  • Genitourinary chlamydia: at 4 weeks and again at 3 months
  • Gonorrhea: within 3 months

Treatment of active sexually transmitted infections in mothers can prevent most cases of newborn conjunctivitis. ^[1]

At birth ^[1][5]

• Provide all newborns with routine ophthalmic antibiotic prophylaxis within 1 hour of birth. ^[1][5]
  • Preferred: erythromycin ophthalmic ointment
  • Alternative: azithromycin ophthalmic solution (off-label) ^[1]
• Neonates whose mothers have an untreated or undertreated infection
  • N. gonorrhea: Give presumptive treatment (see “Antimicrobial therapy for neonatal conjunctivitis”). ^[1]
  • C. trachomatis ^[1]
    • Preferred: close clinical monitoring
    • Patients with barriers to follow-up: Consider systemic antibiotics (see “Antimicrobial therapy for neonatal conjunctivitis”).
  • Active maternal genital herpetic lesions
    • Perform neonatal HSV testing. ^[3]
    • Monitor closely under the guidance of infectious diseases.
    • Consider acyclovir for neonates born to mothers who have recently contracted HSV. ^[3]

If maternal screening was not performed during pregnancy, test for C. trachomatis and N. gonorrhoeae during labor or delivery. ^[1]