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Ophthalmia neonatorum is the most common infection in the first month of life and can have serious systemic as well as ophthalmic morbidity. This article discusses the differential diagnosis and treatment of conjunctivitis in the neonate. Controversies in method of prophylaxis are reviewed.
BACKGROUND: Ophthalmia neonatorum still blinds approximately 10,000 babies annually worldwide. Identification of contributory maternal perinatal factors could possibly predict which babies are at greater risk for this disease. METHODS: In a randomized prospective study of ophthalmia neonatorum in Kenya, we studied the effect of prophylaxis with povidone-iodine, silver nitrate, and erythromycin in 3117 neonates. Four perinatal factors that may promote ophthalmia neonatorum were investigated: maternal vaginitis, birth in a nonsterile environment, presence of meconium at birth, and postnatal development of endometritis. RESULTS: No significant difference in the general ophthalmia neonatorum rate was found for any of the four factors (P > .14 by Fisher exact test). However, with regard to venereal ophthalmia neonatorum, the 26 infants born to mothers with vaginitis had a relative risk 5.1 times that of the rest of the infants (P = 0.0013). Their relative risk to develop gonococcal ophthalmia neonatorum in particular was 24.9 times the rest of the neonates (P = 0.0000031). Prophylaxis was with povidone-iodine in 12 infants, silver nitrate in two, and erythromycin in 12. The frequency of ophthalmia neonatorum was 25%, 100%, and 33%, respectively (differences not significant). CONCLUSION: Neonates born to mothers with vaginitis should be carefully observed for the first postnatal month for the development of ophthalmia neonatorum, even though a prophylactic agent has been used.
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Ophthalmia neonatorum is defined as conjunctivitis appearing during the first month of life. The differential diagnosis includes chemical, bacterial, viral, and other pathogens, including Neisseria gonorrhoeae, herpes simplex, and Chlamydia trachomatis. Neisseria meningitidis is not commonly specifically included in the differential.
Although prophylactic eyedrops to treat ophthalmia neonatorum is mandated nationwide, states and hospitals are free to choose specific drugs. To compare two of these agents, we studied the incidence and characteristics of ophthalmia neonatorum in two UCLA teaching hospitals over a five-year period. One, which used 1% silver nitrate solution exclusively, had 50 cases in 34,772 births, a frequency of 0.14%. The other used 0.5% erythromycin ointment exclusively and had 43 cases in 12,652 births, a frequency of 0.34%. Ophthalmia neonatorum was more frequent in the hospital using erythromycin (p less than 0.001), as was chlamydial conjunctivitis (p less than 0.02). Although not statistically significant, gonococcal conjunctivitis was found in four infants, all in the hospital using silver nitrate. Because silver nitrate was found more effective in decreasing the total frequency of all cases of ophthalmia neonatorum, and cases caused by Chlamydia and gram-negative bacteria specifically, this drug still should be considered as a primary prophylactic agent against ophthalmia neonatorum.
BACKGROUND: Neonatal conjunctivitis (ophthalmia neonatorum) continues to cause blindness because the agents used prophylactically to prevent this condition are not completely effective and are not widely available in many parts of the world. Povidone-iodine ophthalmic solution is an effective antibacterial agent with broad antibacterial and antiviral activity to which no bacteria are known to be resistant, and it is far less expensive and less toxic than the agents currently used to prevent neonatal conjunctivitis. METHODS: We conducted a masked, prospective trial involving 3117 infants born over a period of 30 months in a hospital in Kenya. Shortly after birth each infant received a 2.5 percent solution of povidone-iodine (n = 1076), a 1 percent solution of silver nitrate (n = 929), or 0.5 percent erythromycin ointment (n = 1112) in both eyes. Randomization was achieved by rotating the three medications after each was used for a week. RESULTS: Of the neonates treated with povidone-iodine, 13.1 percent had infectious conjunctivitis, as compared with 17.5 percent of those treated with silver nitrate (P < 0.001) and 15.2 percent of those treated with erythromycin (P = 0.01). Povidone-iodine was more effective against Chlamydia trachomatis than was silver nitrate (P < 0.001) or erythromycin (P = 0.008). There were 104 cases of noninfectious conjunctivitis (9.7 percent) in the povidone-iodine group, as compared with 129 in the silver nitrate group (13.9 percent, P < 0.001) and 148 in the erythromycin group (13.3 percent, P = 0.004). Many cases of noninfectious conjunctivitis were probably due to a toxic reaction to the treatment itself. The incidence of Neisseria gonorrhoeae and Staphylococcus aureus infections was similar in the three groups. CONCLUSIONS: A 2.5 percent ophthalmic solution of povidone-iodine as prophylaxis against ophthalmia neonatorum is more effective than treatment with silver nitrate or erythromycin, and it is less toxic and costs less.
Silver nitrate prophylaxis against ophthalmia neonatorum due to Neissera Gonorrhoeae was introduced by Crédé in 1884, when he instilled a drop of 2% silver nitrate into the cul-de-sac of a newborn. Today, the prime cause of ophthalmia neonatorum is infection by Chlamydia trachomatis. The high incidence of this type of conjunctivitis is due to the frequent exposure of the newborn during delivery and to the ineffectiveness of silver nitrate as a prophylaxis against Chlamydia. In the study reported here, 198 infants less than one month old were examined because of severe bilateral conjunctivitis. In the first week of life a chemical irritation caused by Crédé's prophylaxis was found in the majority (59.7%), but in the second and third weeks infections with Chlamydia trachomatis were found in 27% of all cases. Bacteria were responsible for the infection in 52% of the cases. No gonococci were found in any of the patients examined in the course of the study.
The problem of ophthalmia neonatorum due to penicillinase-producing Neisseria gonorrhoeae (PPNG) has grown with the increasing prevalence of PPNG strains in Singapore. The epidemiological trends, clinical features, and treatment of ophthalmia neonatorum due to PPNG have been determined from the case histories of 11 babies with this condition treated between 1978 and 1980. All 11 cases were cured with a single intramuscular injection of kanamycin 0.5 g and 1% kanamycin eyedrops instilled for three days. In six of the 11 mothers, a non-PPNG strain was isolated.
Ophthalmia neonatorum in small babies is a common problem in neonatal units in Al Ain, but is infrequently associated with sexually transmitted disease agents. A study of 81 babies with ophthalmia neonatorum showed that 81.5% had bacterial or fungal infections. Staphylococcus aureus was the commonest causative organism followed by Escherichia coli and Pseudomonas aeruginosa while Chlamydia trachomatis and Neisseria gonorrhoeae were responsible for less than 5% of all cases. The disease was predominantly mild to moderately severe and easily treated with topical broad-spectrum antibiotic agents which are effective against Gram-positive and Gram-negative bacteria, including hospital-associated strains. The most effective antimicrobial agents were gentamicin topically or ceftriaxone systemically.
A case of chlamydial ophthalmia neonatorum is presented. The importance of early diagnosis and treatment is discussed.
In a Nairobi hospital where ocular prophylaxis against ophthalmia neonatorum has been discontinued, 1,019 women were screened for Neisseria gonorrhoeae and Chlamydia trachomatis during labour and 7 and 28 days postpartum. The prevalence of gonococcal infection was 7% and that of chlamydial was 29%. 52.4% of gonococcal isolates produced penicillinase. The incidence of ophthalmia neonatorum was 23.2 per 100 live births, and incidences of gonococcal and chlamydial ophthalmia were 3.6 and 8.1 per 100 live births, respectively. Of 181 cases of neonatal conjunctivitis, 31% were caused by C trachomatis, 12% by N gonorrhoeae, and 3% by both. In 67 babies exposed to maternal gonococcal infection and 201 exposed to maternal chlamydial infection, rates of transmission to the eye were 42% and 31%, respectively, and to the throat were 7% and 2%. Gonococcal transmission rate was higher in mothers with concomitant chlamydial infection (68%; p = 0.01). Postpartum endometritis was associated with ophthalmia neonatorum (p less than 0.001). Ocular prophylaxis at birth for gonococcal ophthalmia should be reintroduced.
117 infants with gonococcal ophthalmia neonatorum, including 27 with infections due to penicillinase-producing Neisseria gonorrhoeae, were treated as outpatients with five different regimens of single-dose intramuscular kanamycin (75 mg or 150 mg) with saline eye washes, gentamicin eye ointment, or chloramphenicol eye drops. There were no treatment failures among 68 patients treated with 75 mg or 150 mg kanamycin and gentamicin eye ointment (for 3 days). However, the minimum and maximum cumulative probabilities of cure of single-dose kanamycin with saline eye washes (for 3 days) were only 60% and 89%. 1 patient of 15 treated with 150 mg kanamycin plus chloramphenicol eye drops did not respond to treatment. Postgonococcal conjunctivitis developed in 14 (12%) infants, of whom 13 had positive cultures for Chlamydia trachomatis. Nasopharyngeal infection with N gonorrhoeae was eradicated in 9 of 11 infants colonised.
In a retrospective study of ophthalmia neonatorum seen in Middle Road Hospital between 1983 and 1986, 68% were caused by Neisseria gonorrhoeae. 40% of the Neisseria gonorrhoeae isolates were PPNG strains. For therapy of gonococcal ophthalmia neonatorum, 1% kanamycin eyedrops combined with a single intramuscular injection of kanamycin or a third generation Cephalosporin (Ceftriaxone or Cefotaxime) were all effective regimens. The use of intramuscular kanamycin was stopped because of concern for ototoxicity. Chlamydia trachomatis remains an uncommon cause of ophthalmia neonatorum in Singapore, in only 2 cases was this agent identified.
Haemophilus influenzae is an occasional cause of ophthalmia neonatorum. Recently, this organism has exhibited a change in its epidemiology and has been identified as a cause of severe neonatal infections. Ophthalmologists should be aware of the changing susceptibility of neonates to severe infections with H influenzae and the possibility that H influenzae ophthalmia neonatorum can be associated with these infections.
The microbiology, epidemiology and pathophysiology of ophthalmia neonatorum are reviewed with special emphasis on its prevention and management in the developing world. Although prophylaxis should be mandatory, no single topical agent is effective to prevent the ocular complications of both Neisseria gonorrhoea and Chlamydia trachomatis. Where levels of resistance to tetracyclines are low, however, tetracycline eye ointment is permissible for ocular prophylaxis. Eye prophylaxis has a relatively low failure rate. Management of ophthalmia neonatorum should be syndromic and systemic. Contact tracing is an integral part of the management.
We evaluated the use of silver nitrate drops and tetracycline ointment for the prophylaxis of ophthalmia neonatorum in a controlled trial involving 2732 newborns in Nairobi, Kenya. The overall rates of prevalence of intrapartum maternal gonococcal and chlamydial infection were 6.4 and 8.9 percent, respectively. After prophylaxis with silver nitrate, the incidence rates of gonococcal, chlamydial, and nongonococcal, nonchlamydial ophthalmia neonatorum were 0.4, 0.7, and 6.2 percent, respectively, whereas after prophylaxis with tetracycline, the rates were 0.1, 0.5, and 4.5 percent. The attack rates of gonococcal ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae at birth were 7.0 percent in those receiving silver nitrate and 3.0 percent in those receiving tetracycline (95 percent confidence interval for the difference in rates, -3.4 to 11.4 percent). As compared with historical controls, the incidence of gonococcal ophthalmia neonatorum decreased 83 percent among infants treated with silver nitrate and 93 percent among those treated with tetracycline. Failure of prophylaxis was associated with postpartum maternal endometritis (P = 0.05). Among newborns exposed to maternal infection with Chlamydia trachomatis, chlamydial conjunctivitis developed in 10.1 percent given silver nitrate and in 7.2 percent given tetracycline (95 percent confidence interval for the difference in rates, -4.7 to 10.5 percent), yielding reductions in the incidence of chlamydial ophthalmia of 68 and 77 percent, respectively, as compared with the historical controls. We conclude that tetracycline is as effective as silver nitrate in preventing gonococcal ophthalmia neonatorum.