Incidence

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

Presentation

Conjunctival erythema
Purulent discharge
Lid oedema
Look for involvement of any other system, e.g. herpes vesicles, infected scalp pH site.

History

Maternal history

sexually transmitted diseases or exposure.
results of high vaginal, cervical and urethral swabs in pregnancy
length of labour and duration of membrane rupture.

Diagnosis

Bacterial culture Do this first unless Chlamydia is strongly suspected if Gram stain finds Gram -ve bacilli, seriously consider Pseudomonas and consider sepsis screen and parenteral anti-Pseudomonal antibiotics	dry swab for gram stain. wet swab for culture (eye swabs received on an infant <4 weeks of age routinely cultured for N. gonorrhoeae).
Chlamydia	Conjunctival scrapping - done with cotton-tipped wire swab applied vigorously to the lower palpebral conjunctiva. Purple swab. detection of C.trachomatis by EIA (processed 5 days/week), PCR available on request (more expensive, performed 3x/week). Generally don’t look for this earlier than 5 days of age.
HSV	Green viral culture swab (processed 5 days/week).

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

Causes

Non-Infectious	Silver Nitrate drops Corneal abrasion following trauma at delivery. Glaucoma (watch for corneal clouding or proptosis, is associated with portwine stains in the ophthalmic region). Foreign body. Nasolacrimal duct obstruction may cause ‘sticky’ eyes.
Infectious		Organism	Age of Onset	Clinical Features	Therapy
		Staphylococcus aureus	2-5 days	Unilateral, crusted purulent discharge	Topical soframycin drops
		Neisseria gonorrhoeae ^#	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.
		Streptococcus pneumoniae, Haemophilus spp, Enterococci	2 days	Mild purulent conjunctivitis	Topical soframycin drops
		Pseudomonas aeruginosa ⁺	5-18 days	Oedema and erthyema of lid, purulent discharge.	IV anti-pseudomonal antibiotics. Topical polymyxin.
		Chlamydia trachomatis^*	2-20 weeks	Unilateral or bilateral, mild conjunctivitis, copious purulent discharge.	PO erythromycin 50mg/kg/day x 14d (bid or qid).
		Herpes simplex		Conjunctivitis with vesicles elsewhere	Acyclovir 30mg/kg/day IV tid x 14-21d. Topical acyclovir. 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.

References

1 Tsang B, Infectious conjunctivitis in childhood. New Ethics Nov 1994, 1-8.

2 Remington and Klein. Infectious diseases of the fetus and newborn. 4th Ed. 1995.

Antibiotic Eye Preparations

Generic Name	Trade Name and Preparation	Usual susceptibility				Potential Adverse Effects
Generic Name	Trade Name and Preparation	Staphylococci	Steptococci	Gram negative bacilli	Pseudomonas	Potential Adverse Effects
Chloramphenicol	Chlomin drops, ointment Chloromycetin drops, ointment Chloroptic drops, ointment Chlorsig drops, ointment Minims drops	+	+	+	-	May obscure results of tests for Chlamydia; rarely marrow aplasia.
Chloramphenicol/ polymyxin B	Chloromyxin drops, ointment	+	+	+	+	May obscure results of tests for Chlamydia; rarely ototoxicity or marrow aplasia.
Framycetin	Soframycin drops, ointment	+	-	+	-	Sensitisation; development of resistant organisms.
Fusidic acid	Fucithalmic drops	+	+	-	-	Rarely transient stinging.
Gentamicin	Genoptic drops Minims drops	+	-	+	+	Sensitisation; development of resistant organisms.
Gramicidin/ neomycin polymyxin B	Neosporin drops	+	+	+	+	Sensitisation; development of resistant organisms; rarely ototoxicity.
Sulphacetamide	Acetopt drops Bleph Liquifilm drops Minims drops	+	+	+	-	Inactivated by pus and tissue breakdown products.
Tetracycline	Achromycin ointment	+	+	+	-
Tobramycin	Tobrex drops, ointment	+	-	+	+	Sensitisation; development of resistant organisms.

1	Tsang B, Infectious conjunctivitis in childhood. New Ethics Nov 1994, 1-8.
2	Remington and Klein. Infectious diseases of the fetus and newborn. 4th Ed. 1995.