Neonatal Conjunctivitis / Ophthalmia neonatorum

Originally published at Pediatric EM Morsels on January 29, 2011. Reposted with permission.

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Neonatal Conjunctivitis

  • As the name suggests, it is conjunctivitis that develops within the 1st 4 weeks of life.
  • Traditionally teachings about etiologies:
    • Chemical – day #1, mild conjunctivitis; less common now (less silver nitrate use)
    • GC – days #2-7, SEVERE conjunctivitis; can become disseminated (problem)!
    • Chlamydia – days 5-14, mild conjunctivitis; may lead to pneumonia
    • Other bugs/viruses – days 5-14, mild conjunctivitis; most prevalent

Unfortunately, nothing is that simple, and the concern for disseminated GC often leads to full sepsis work-ups.

  • The Red Book can be used to support this approach… and also a less aggressive approach.
  • If GC is suspected, “cultures of blood, eye discharge, or other sites of infection, such as CSF, should be performed…” and “Infants with gonococcal ophthalmia should be hospitalized and evaluated for disseminated infection (sepsis, arthritis, meningitis).”
  • Chlamydial infection, however, are much more common (GC accounts for <1% of neonatal conjunctivitis: even less disseminated complications of it).
  • Chlamydial infection is managed with ORAL antibiotics as an outpatient.

Where’s that leave us?

  • Well, here are two approaches that I think are justifiable.
  1. Do the full sepsis work-up. Rationalize that, in the ED, there is not a clinical way to determine whether you are dealing with GC and because of the potential concerns, cover all of your bases. This is the most conservative certainly.
  2. Send a blood culture and send a culture and PCR (for Chlamydia) of the ocular discharge. Send a gram stain of the ocular discharge and admit the child. If the Gram stain is suspicious for GC, then the decision to LP and start abx can be made.
    • The emergent administration of antibiotics is less of an issue and, as long as the child is doing well, this decision can be made in concert with the admission team.
  • With either plan, the most important therapy needs to be started; eye irrigation.

Ophthalmia neonatorum in Red Book.
Much appreciation to Dr. Amina Ahmed for her rational insight.

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