Neonatal Conjunctivitis : Causes, Symptoms, and Treatment Options

Neonatal conjunctivitis is often called neonatal ophthalmia (Latin name). This is conjunctivitis that occurs in 1-month-old neonates with clinical signs of erythema and edema of the eyelids and palpebral conjunctiva, purulent ocular discharge with one or more polymorphonuclei per oil-soaked area of Gram-stained conjunctival smear. Defined as a thing.

Neonatal ophthalmia causes blindness in approximately 10,000 babies worldwide each year. The main causes of neonatal ophthalmia are, in order, chemical inflammation, bacterial infection, and viral infection.

Most neonatal infectious conjunctivitis is caused by bacteria. Bacterial causes include sexually transmitted pathogens (Chlamydia trachomatis and Neisseria gonorrhoeae), microorganisms from the skin (Staphylococcus aureus), and the maternal gastrointestinal tract (Pseudomonas spp.).

Inflammation usually heals on its own within a few days. Therefore, simple Gram staining and routine bacterial culture are often the only investigations required in most cases. A simple examination may suffice, but appropriate treatment is necessary, especially for Chlamydia trachomatis and Neisseria gonorrhoeae infections, which can lead to systemic complications and severe blindness. In addition to bacteria, herpes viruses can also cause conjunctivitis in newborns.

The pathogens that cause neonatal conjunctivitis are usually transmitted from an infected mother's birth canal, but some are transmitted from the environment in the immediate vicinity of the mother. The vaginal tract of the mother during the last pregnancy, premature rupture of the membrane , and prolonged labor.

Neonatal conjunctivitis after cesarean section may be due to premature rupture of the endometrium due to intrauterine chlamydial infection, or transplacental or transmembrane infection of these organisms.

The epidemiology of neonatal ophthalmia was altered by the prophylactic use of 1% silver nitrate solution (Crede method). Widespread use of Crede prophylaxis has resulted in significant reductions in the incidence of ophthalmitis in the United States, Europe, and the United Kingdom.

Not effective against chlamydia. Silver nitrate prophylaxis is not currently used because it is ineffective in preventing chlamydial infection and tends to cause chemical conjunctivitis.This prophylaxis has been replaced by the use of erythromycin or tetracycline ointment.

Epidemiology

Neonatal ophthalmia is a global problem. The pathogens responsible for infection vary geographically due to differences in the prevalence of maternal infection and prophylactic use of antibiotics and silver nitrate solutions. In developed countries, Chlamydia is reported to be the most common infectious agent causing eye disease compared to Neisseria gonorrhoeae.

However, both chlamydia and gonorrhea infections are common in developing countries. In Malaysia, lack of regular precautions and pecyclinase-producing N. Gonorrhea (PPNG) strain. Due to underreporting, the actual incidence is unknown.

A study of gonococcal ophthalmia neonates in Kelantan showed that the proportion of cases infected with penicillin-resistant strains of Neisseria gonorrhoeae increased from 6.4% to 25.9%. Pecilinase-producing strains are believed to originate from the Southeast Asian region, namely Bangkok, and N. The isolated gonorrhea was due to PPNG.

The prevalence of ophthalmitis due to gonococcal infection is reported to be 0.04/1000 live births in Belgium and the Netherlands and 0.3/1000 live births in the United States.

On the other hand, the prevalence of gonorrhea among pregnant workers in African countries ranges from 4% to 15%. Approximately 25% to 50% of infants exposed to Chlamydia trachomatis and Neisseria gonorrhoeae develop neonatal conjunctivitis without prophylaxis.

Etiology

Neonatal ophthalmia can be divided into aseptic and septic forms. The sterile type (chemical conjunctivitis) is commonly secondary to ocular prophylaxis silver nitrate drops. Newborn septic conjunctivitis is primarily caused by bacterial or viral infections. Chlamydia trachomatis and Neisseria gonorrhoeae, two sexually transmitted disease pathogens, are associated with systemic complications and severe vision loss if left untreated.

Chlamydia trachomatis is the most common cause of neonatal ophthalmia in developed countries due to the prevalence of chlamydia as a sexually transmitted disease. This is because her 60% to 80% of female genital chlamydial infections are asymptomatic. It is more common than gonococcal infections and about four to six times more common than herpes virus infections.

Neisseria gonorrhoeae is the second most common organism that causes neonatal ophthalmitis, but is the most virulent infectious agent of neonatal conjunctivitis. Prophylaxis at birth was necessary as it was the most common cause of blindness in the first year of life.

Neonatal gonococcal ophthalmia was eradicated in the United States in the 1950s. However, with the increasing incidence of gonococcal infection in adults and the development of antimicrobial resistance, it is now relapsing.

Other microbial causes of ophthalmitis include Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, Klebsiella species, and Pseudomonas aeruginosa.

Clinic Features

Chlamydia trachomatis genital serovars D-K cause neonatal conjunctivitis. It develops later than gonococcal conjunctivitis. The incubation period is 5-14 days, and colonization of the eye after birth does not necessarily lead to infection.

Nearly 40% of infected neonates develop hydrous conjunctivitis, which later becomes more profuse and suppurative. Most cases are mild and self-limiting, but some are severe with eyelid swelling, edema, papillary reaction, pseudomembranes, peripheral pannus, and corneal involvement.

If left untreated, 10-20% of cases develop infantile pneumonia. Other extraocular involvement of chlamydia include nasopharyngeal, rectal, and vaginal colonization and B. infantile pneumonia syndrome.

The incubation period is 2-5 days. However, premature rupture of the membrane can occur early. It is usually bilateral. Conjunctivitis is characterized by severe hyperacute purulent discharge, eyelid edema, and chemosis.

Neisseria gonorrhoeae has the ability to invade the intact corneal epithelium, causing corneal epithelial edema and corneal ulceration, which, if undetected, can progress to corneal perforation and endophthalmitis.

In order to avoid these grave repercussions, the baby must always be checked for gonorrhea in cases of newborn conjunctivitis can also cause systemic complications of Herpes simplex keratoconjunctivitis in infants usually presents with a systemic herpetic infection.

Blisters around the eyes and corneal lesions are also common. They may appear as swollen eyelids with reddening of the eyes, or less commonly as narrowing of the tear ducts. Neonatal ophthalmia due to other microbial causes is usually mild without corneal and systemic involvement.

Diagnosis

Culture of the watery ocular discharge to hunt for viruses or bacteria.
Slit-lamp examination to check for eyeball surface injury.

Neonatal ophthalmia is a clinical diagnosis made primarily by observing signs and symptoms. Clinically distinguishing between the different forms of neonatal conjunctivitis can be difficult. Laboratory diagnosis is therefore paramount to making the correct diagnosis and initiating the best treatment.

Gram-stained and Giemsa-stained conjunctival smears should be obtained from the palpebral conjunctiva of all infants with neonatal conjunctivitis. The presence of intracellular Gram-negative diplococci (IGND) has high sensitivity, specificity, and predictive value.

Chlamydia trachomatis can be isolated in 60-80% of all infants by the presence of intracytoplasmic inclusion bodies on Giemsa staining.

Conjunctival swabs (direct immunofluorescence assay) smeared on slides and stained with a Chlamydia trachomatis-specific fluorescent monoclonal antibody often reveal the presence of impressive numbers of punctate, fluorescent chlamydia bodies resembling a "starry sky".

This antigen detection test is still considered the "gold standard" for diagnosing chlamydia infection. When compared to McCoy cell culture, PCR tests for the diagnosis of chlamydial conjunctivitis have the benefits of early detection and high specificity.

Other laboratory tests used to diagnose chlamydial infection include the microimmunofluorescence (MIF) assay to detect Chlamydia trachomatis IgG and IgM antibodies, and the Elisa test.

Treatment

All infants with neonatal conjunctivitis should be included because neonatal ophthalmia is an ocular emergency. Specific treatments are available for different types of neonatal conjunctivitis, and treatment should be based on clinical presentation and laboratory diagnosis (Gram and Giemsa staining).

It is important to treat infants with systemic rather than topical agents to prevent systemic spread of organisms. Because the pathogen is a sexually transmitted disease, the mother and her sexual partners need to be treated with respect.

Current WHO guidelines for the treatment of sexually transmitted infections recommend that both N. gonorrhea and C. trachomatis 39). The co-infection rate is estimated at approximately 2%.

Neonatal ophthalmia due to C. trachomatis.

The erythromycin syrup 50 mg/kg/day orally in four split doses for 14 days is recommended by the American Academy of Paediatrics and the World Health Organisation. Tetracycline or topical erythromycin may be used in conjunction with other treatments.

The effectiveness of oral erythromycin as topical erythromycin in eliminating nasopharyngeal carriers, treating concomitant pneumonia, and reducing conjunctivitis recurrence are additional benefits. Doxycycline 100 mg orally twice day for 7 days, or azithromycin 1 g orally once, should be administered to infected partners.

Neonatal ophthalmia due to Neisseria gonorrhoea.

Treatment of gonococcal conjunctivitis is penicillin G 100,000 units/kg/day intravenously for 1 week. N. gonorrhoeae isolates are resistant to penicillin in many urban areas of the United States. Across Africa, the proportion of pecyclinase-producing N. gonorrhea ranges from 18% to 57%, with a range in many other parts of the world (50% to 60%).

Therefore, in areas where pecyclinase-producing strains are endemic, 3rd generation cephalosporin drugs should be used by him for 7 days. A single dose of ceftriaxone 50 mg/kg (up to 125 mg) is highly effective and recommended by WHO guidelines.

Alternatives include spectinomycin 25 mg/kg (up to 75 mg) as a single IM dose and kanamycin 25 mg/kg (up to 75 mg). ). An infant's eyes should be washed frequently with saline to remove discharge.