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NICU guideline identifier

Conjunctivitis in the neonate

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Incidence

2-12% of newborns develop conjunctivitis in the first 28 days of life.

Presentation

  • Conjunctival erythema 
  • Purulent discharge 
  • Lid oedema 

History

Maternal history of:

  • sexually transmitted diseases or exposure.
  • results of high vaginal, cervical and urethral swabs in pregnancy

Investigations

  • Look for involvement of any other system, e.g. herpes vesicles, infected scalp pH site. 
  • In a well term baby take swab and consider saline drops alone while awaiting swab results. The most common cause of conjunctival discharge/sticky eye is naso lacrimal duct obstruction. Often self-limiting. 

Diagnosis

Bacterial culture
Do this first unless Chlamydia is strongly suspected.

Swab for MC & S (standard blue swab).
Ask lab to process urgent gram stain for gonococcus if suspected. In working hours a special swab can be used to test for N.gonorrhea
If Gram stain finds Gram -ve bacilli, seriously consider Pseudomonas and consider sepsis screen and parenteral anti-Pseudomonal antibiotics PCP (BD probe tec swabs). Can also be used for Chlamydia (use small blue).
Chlamydia
Tends to present between days 5-14. Swab as above (Chlamydia PCR)
Viral Conjunctivitis, Adenovirus, Enterovirus and HSV
Green viral culture swab for HSV(processed 5 days/week).

NB: Transport all specimens ASAP to Microbiology Laboratory, LabPlus.

Causes

Non-Infectious

  • Nasolacrimal duct obstruction may cause 'sticky' eyes.
  • Corneal abrasion following trauma at delivery.
  • Glaucoma (watch for corneal clouding or proptosis, is associated with portwine stains in the ophthalmic region).
  • Foreign body.

Infectious

Organism Age of Onset Clinical Features Therapy
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus spp
Enterococci
2-5 days Unilateral, crusted purulent discharge Topical Framycetin (soframycin) drops qds for 5 days 
Neisseria gonorrhoeae #
Infants who are positive need to be evaluated for disseminated infections
3 days to 3 weeks Bilateral, hyperaemic, chemosis, copious thick white discharge Ceftriaxone 50mg/kg IV/IM as a single dose (maximum 125mg),
Saline irrigations hourly until exudate resolves
Pseudomonas aeruginosa +  5-18 days Oedema and erthyema of lid, purulent discharge. IV anti-pseudomonal antibiotics. 
Topical Gentamicin.
Chlamydia trachomatis * 5-14 days  Unilateral or bilateral, mild conjunctivitis, copious purulent discharge.  PO erythromycin 50mg/kg/day x 14d (qid)
Alternative, 5 days Azithromycin syrup

(= pertussis dosing 10mg/kg/day and 5mg/kg day 2-5)
Herpes simplex    Conjunctivitis with vesicles elsewhere
Need ophthalmology review within 24 hours. 
Acyclovir 30mg/kg/day IV tid x 14-21d.
Topical acyclovir 3% 5 times daily.
Isolation.

# Uncommon, potential for serious consequences - severe keratitis and endophthalmitis. Requires early recognition and treatment. Needs blood and CSF culture. Consider concomitant chlamydial infection if poor response to cephalosporin. Parents require investigation and screening.

+ Risk of rapid progression from purulent discharge to denuding of corneal epithelium, and perforation of cornea. The anterior chamber can fill with fibrinous exudate, iris can adhere to cornea and later blood vessel invasion. The late ophthalmic complications can be followed by bacteraemia and septic foci.

* Most common pathogen, 20-50% of exposed infants will develop chlamydia conjunctivitis, 10-20% will develop pneumonia. If relapse occurs repeat course of erythromycin for further 14 days. Parents require treatment.

NB: Chloramphenicol in topical therapy can obscure results of tests for chlamydia.

In cases of Chlamydia/N.gonorrhea, the LMC (midwife) needs to be informed.

Antibiotic eye preparations

Generic Name Trade Name & Preparation Usual susceptibility Potential Adverse Effects
Staphylococci Steptococci Gram -ve bacilli Pseudomonas
Chloramphenicol 0.5%
QDS for 5 days
Chlomin drops, ointment
Chloromycetin drops, ointment
Chloroptic drops, ointment
Chlorsig drops, ointment
Minims drops
+ + +  - May obscure results of tests for Chlamydia; rarely marrow aplasia 
Framycetin
(Soframycin)
Framycetin 5% drops, ointment    + + -   - May obscure results of tests for Chlamydia;  rarely ototoxicity or marrow aplasia
Fusidic acid (Sodium fusidate)  Fucithalmic 1% drops  +  - +  - Rarely transient stinging. 
Gentamicin  Genoptic 0.3% drops
Minims drops 
+  - + + Sensitisation; development of resistant organisms. 
Sulphacetamide  Acetopt drops
Bleph 10% Liquifilm drops
Minims drops 
+ + +  - Inactivated by pus and tissue breakdown products. 

References

  1. Red Book 2012 Report of the Committee on Infectious Diseases, American Academy of Paeds.
  2. Remington and Klein. Infectious diseases of the fetus and newborn. 4th Ed. 1995.
  3. Starship Child Health Guidelines, Infections in and around the eye.

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Document Control

  • Date last published: 30 November 2013
  • Document type: Clinical Guideline
  • Services responsible: Neonatology, Paediatric Infectious Diseases
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years