Conjunctivitis Neonatal (Ophthalmia Neonatorum) - Guideline for the Management of

Publication: 01/09/2010  
Last review: 27/06/2019  
Next review: 27/06/2022  
Clinical Guideline
CURRENT 
ID: 1678 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Neonatal Conjunctivitis (Ophthalmia Neonatorum)

Summary
Conjunctivitis Neonatal (Ophthalmia Neonatorum)

Diagnosis
Conjunctivitis in the newborn is a relatively common condition that may not always be infective in origin. Clinical signs to look for are:

  • Mucoid or mucopurulent discharge from one or both eyes
  • Conjunctival congestion,
  • Eyelid stuck,
  • Oedema of the eye lid and
  • Erythema of lids
  • Conjunctival membrane in severe disease.

The more pronounced these signs are the more severe the conjunctivitis. Classify conjunctivitis as:

  • Mild - some exudate from the eyes with crusting after sleep that can be easily cleaned away. No erythema or swelling of eye or lids
  • Established - pus, exudate, lid and conjunctival erythema and swelling.
  • Systemic - as moderate + signs of systemic infection

Suspect gonococcal or chlamydial infection when conjunctivitis appears with:

  • Maternal history of gonococcal or chlamydial infection
  • Maternal history of other sexually transmitted diseases
  • High risk maternal life style
  • Concurrent suspected infectious respiratory illness
  • Symptoms specific to either pathogen - see below.

However, the history may not reveal any clues and if gonococcal or chlamydial infection is suspected it must be treated as such.

Investigations required
Mild: no investigations unless progression to moderate severity (see below)
Established: swab pus for MC&S, Gen Probe Aptima swab (gonococcus/Chlamydia) if suspected and Copan swab for bacterial conjunctivitis.
Systemic:

  • swab pus for MC&S
  • Gen Probe Aptima swab for gonococcus or Chlamydia if suspected
  • Copan swab for bacterial conjunctivitis
  • Gram stain-If there is lot of discharge collect the pus in a clear bottle directly from discharge.
  • Blood cultures - peripheral and central if central access device in situ
  • FBC, CRP, LFTs and electrolytes
  • Consider other samples depending on concurrent clinical findings e.g. urine, chest, CSF, pharyngeal swabs.

The laboratory should be called to alert them that an urgent sample is on its way. (During normal working hours Ext. No0113-392-3499, out of hours bleep 2543 or contact duty laboratory Microbiologist via switchboard.) Gen Probe Aptima swabs are available from microbiology.

Non-antimicrobial management.
All: Regular cleaning of the lids with sterile 0.9% sodium chloride solution 4-6 hourly as necessary.
Systemic: Assess and manage the baby according to neonatal sepsis guidelines. If gonococcal or chlamydial infection is clinically suspected then the appropriate treatment should be given (see below).
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Empirical (initial) antimicrobial management.
Mild: none
Established or systemic: Systemic antibiotics are adequate but topical chloramphenicol drops: 1 drop every 2 hours to each eye may be added. Regular cleaning of the eyes with sterile 0.9% saline however, with systemic treatment should be adequate.

onsider referral to ophthalmology after treatment has been initiated: severe cases and gonococcal/chlamydial conjunctivitis.

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Background

Conjunctivitis is inflammation of the conjunctiva that may cause an erythematous eye with or without swelling and exudate. Any conjunctivitis presenting in the first four weeks after birth is classified as neonatal conjunctivitis (ophthalmia neonatorum) (1). Neonatal conjunctivitis can be noninfective or infective cause during passage through an infected birth canal. Since April 2010 Ophthalmia neonatorum is no longer  a notifiable disease in UK.

Causes

  1. Uncanalised naso-lacrimal duct. The naso-lacrimal duct is usually fully canalised by the 8th month of gestation. If there is delay in this canalisation the newborn may have excessive tearing and crusting of the eye. This may become infected and cause conjunctivitis although this is unusual. Erythema is usually present with infection and not with uncomplicated lacrimal duct obstruction
  2. Chemical – It is very rare now as we don’t use any prophylaxis for Chlamydial conjunctivitis. Characterised by
    • Mild lid oedema
    • Clear, sterile eye discharge
    • Onset <24h after onset of prophylaxis
      • Resolves within 48h
  3. Infective conjunctivitis – can be caused by
    • Neisseria gonorrhoeae (gonococcal conjunctivitis)
    • Chlamydia trachomatis (chlamydia conjunctivitis)
    • Herpes simplex virus
    • Other infective organisms
      • Gram-positive organisms include Staphylococcus aureus, Streptococcus pneumoniae, oral streptococci, beta-haemolytic streptococci and Staphylococcus epidermidis (1).
      • Gram-negative organisms, such as Escherichia coli, Klebsiella pneumoniae, Serratia marcescens, Haemophilus spp, Proteus spp., Enterobacter spp., and Pseudomonas spp., also have been implicated. (1)

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Clinical Diagnosis

Clinical signs to look for are

  • a purulent discharge,
  • conjunctival congestion,
  • eyelid stuck,
  • oedema of the eye lid and
  • erythema of lids.

The more pronounced these signs are the more severe the conjunctivitis.

The conjunctivitis can be classified as:

  • Mild - some exudate from the eyes with crusting after sleep, that can be easily cleaned away. No erythema or swelling of eye or lids.
  • Established - exudate, lid and conjunctival erythema and/or swelling.
  • Systemic - as moderate plus signs of systemic infection.

Gonococcal or chlamydial infection should be suspected with clinical signs of conjunctivitis. There may be no history but the following may provide clues appear with

  • Maternal history of gonococcal or chlamydial infection
  • Maternal history of other sexually transmitted diseases
  • High risk maternal life style
  • Concurrent suspected infectious respiratory illness
  • Symptoms specific to either pathogen - see below.

[Evidence level D]

Suspected Gonococcal Conjunctivitis

  • The most serious form of conjunctivitis
  • Usually occurring 24-48 hours following birth but may present up to 7 days after delivery.
    • hyperacute conjunctivitis
    • associated with marked lid oedema
    • chemosis (oedema of the mucous membrane of the eyeball and eyelid lining)
    • purulent discharge.
  • Ulceration may occur and rapidly progress to perforation, if treatment is delayed
  • Evaluation of disseminated disease like pneumonitis, otitis, sepsis, arthritis and meningitis is needed.
  • Gram stain shows Gram-negative diplococci
  • N. gonorrhoeae cultured (NB: Moraxella and other Neisseria spp. may result in indistinguishable Gram-stain findings).

Suspected chlamydial infection (including) conjunctivitis

  • Chlamydia is the commonest and infectious cause of sexually transmitted conjunctivitis compared to Gonococcal conjunctivitis. Infection could be self-limiting.
  • Most cases are acute, mild and complications can occur if left untreated.
  • In severe cases complications like Pseudomembranous formation, thickened palpebral conjunctiva, significant peripheral pannus, and/or corneal opacification may be present.
  • Symptoms of conjunctivitis usually present 7-14 days after delivery, but can present up to 28days after birth.
  • Chlamydia may also have systemic manifestations like otitis, rhinitis and pneumonitis most commonly cough and fever (although the classic description is afebrile). Symptoms of pneumonia usually begin in children aged 1-3 months. (Babies with sepsis need to follow the trust sepsis guideline).

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Investigation

Mild
Swabs should not be taken unless

  • symptoms progress.

Established

  • Swab for MC&S.
  • If possibility of gonococcal or chlamydial infection send urgent Gen Probe Aptima swab, specific for these pathogens.
  • Copan swab for bacterial conjunctivitis.
  • Gram stain if there is copious amount of discharge (It needs to be collected in a clear bottle directly from discharge).

Systemic illness with conjunctivitis

  • Swabs eye discharge for MC&S
  • Gen Probe Aptima swab for gonococcus or Chlamydia if suspected
  • Blood culture- peripheral and central if central access device in situ
  • FBC, CRP, LFT and electrolytes
  • Consider other samples for culture e.g. urine, chest, CSF, pharyngeal swabs.
  • The laboratory should be called to alert them that an urgent sample is on its way. (During normal working hours Ext. No0113-392-3499, out of hours bleep 2543 or contact duty laboratory Microbiologist via switchboard. )

[Evidence level C/D]

Note

  • In chlamydial infection swabs are often negative despite infection and a high index of suspicion should be maintained.
  • Gen Probe Aptima swabs and Copan swabs are available from microbiology, the genitor-urinary medicine department. A small supply of Gen Probe Aptima swabs is kept on the neonatal unit.

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Treatment
Non-Antimicrobial Treatment
  • Regular cleaning of the lids with sterile 0.9% sodium chloride solution as necessary
  • If gonococcal or chlamydial conjunctivitis request expert ophthalmology opinion after treatment initiated.

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Empirical Antimicrobial Treatment

Topical antibiotics should be started only after swabs have been taken.

Mild: no topical antimicrobials
Established/systemic: When gonococcal or chlamydial conjunctivitis is suspected systemic targeted antimicrobial treatment should be started. Topical chloramphenicol drops: 1 drop into each eye instilled 2- hourly initially, extending to 6 hourly after 24 hours are not necessary in these 2 conditions.

NB drops are preferable to ointment as irrigation of the eye is part of treatment.
NB. Both eyes should be treated even if only one is symptomatic.

If a baby is unwell with systemic symptoms in addition to conjunctivitis assess and manage the baby according to neonatal sepsis guidelines (detail.aspx?id=201) targeting antibiotic therapy where gonococcal or chlamydial conjunctivitis is suspected

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Directed Antimicrobial Treatment (when microbiology results are known)

Change antibiotics when gram stain results and/or culture results are known.

If Gram negative diplococci are seen on Gram stain, treat as for gonococcal disease.

Gonococcal Conjunctivitis

Ceftriaxone electronic Medicines Compendium information on Ceftriaxone is contraindicated in neonates less than 41 weeks postmenstrual age; neonates over 41 weeks postmenstrual age with jaundice, hypoalbuminemia, or acidosis; concomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in neonates over 41 weeks postmenstrual age—risk of precipitation in urine and lungs

  • Ceftriaxone electronic Medicines Compendium information on Ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg (2002 CDC STD guidelines)
  • Alternative: Cefotaxime electronic Medicines Compendium information on Cefotaxime 100mg/kg IV or IM as a single dose
  • Topical treatment is not required.
  • 0.9% sodium chloride solution irrigation until exudates resolves.
  • Consider discussion with ophthalmologist regarding possible corneal ulceration
  • Refer mother to Genito-urinary medicine

Chlamydial infection (including) conjunctivitis

  • Topical treatment alone is inappropriate and is unnecessary when systemic treatment administered.
  • If systemically well, treatment with 7 days of oral erythromycin
    If systemically unwell, 14 days of IV erythromycin
    ORAL/IV: 12.5mg/kg/dose 6 hourly (14 days).
  • Azithromycin electronic Medicines Compendium information on Azithromycin is used as a second line -20mg/kg,OD for 3 days if there is compliance problem.

Maternal infection which has been treated with a full course of erythromycin either during and/or before this pregnancy.Monitoring for signs of pyloric stenosis is needed as cases are reported with macrolides given under the age of 6 weeks.

  • If no clinical symptoms/signs, no treatment necessary
  • If conjunctivitis, obtain eye swab (for Chlamydia) and immediately start chloramphenicol eye drops/ointment.
  • If Chlamydia positive, 14 days of oral (IV if unwell) erythromycin
  • Refer mother to GU medicine immediately for investigation and treatment.

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Duration of Treatment

Topical antibiotics should be continued for 5 days or 48 hours after the symptoms have settled, whichever is sooner
Chlamydia conjunctivitis: complete 14 days therapy.

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Switch to oral agent(s)

Not applicable for cases not treated with systemic antimicrobials.

Chlamydia switch to oral erythromycin when systemically well and clinically improving.

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Treatment Failure

Suspected gonococcal conjunctivitis

  • Treatment failure is unlikely with this regimen. Follow-up of the baby should, however, involve daily examination of the eyes for the presence of a discharge for at least 1 week.
  • Subsequent development of systemic infection and/or infective arthritis may represent disseminated gonococcal disease, and should be investigated and treated accordingly.

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Provenance

Record: 1678
Objective:

Aims

  • To improve the diagnosis and management of neonatal conjunctivitis

Objectives

  • To provide evidence-based recommendations for appropriate diagnosis and investigation of neonatal conjunctivitis
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of neonatal conjunctivitis
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of neonatal conjunctivitis
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Neonatal conjunctivitis

Target patient group: Babies in the neonatal period
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. KARL E. MILLER, Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006;73(8):1411-1416
  2. Robertson’s Textbook of Neonatology, 3rd Ed.
  3. Centres for disease control and prevention MMWR Recomm Rep. 2006 August 55 (RR11) 1-94
  4. Sexually Transmitted Diseases Treatment Guidelines 2006 Centres for disease control and prevention
  5. 2008 European (IUSTI/WHO) Guideline on the Diagnosis and Treatment of Gonorrhoea.
  6. Andrew Zikic Treatment  of Neonatal Chlamydial conjunctivitis Paediatric Infectious Dis Soc.2018 aug.

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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