What is the treatment for a 3-day-old infant with bilateral chemosis and purulent eye drainage who did not receive erythromycin (antibiotic ointment) at birth?

Treatment of Bilateral Chemosis and Purulent Eye Drainage in a 3-Day-Old Infant

For a 3-day-old infant with bilateral chemosis and purulent eye drainage who did not receive erythromycin eye ointment at birth, systemic antibiotic therapy is required along with topical antibiotics, as this presentation is highly suspicious for gonococcal or chlamydial conjunctivitis. 1, 2

Immediate Assessment and Management

1. Collect specimens before starting treatment:

   • Conjunctival swabs from everted eyelids (not just discharge)
   • Test for both Neisseria gonorrhoeae and Chlamydia trachomatis
   • Ensure specimens contain conjunctival cells, not just exudate 1

2. Empiric treatment should begin immediately without waiting for results:

For suspected gonococcal conjunctivitis:

• Systemic therapy:

  • Ceftriaxone as a single dose (25-50 mg/kg IV or IM, not to exceed 125 mg) 2
  • This is critical as topical therapy alone is inadequate for gonococcal infection

• Topical therapy:

  • Erythromycin ophthalmic ointment (approximately 1 cm) applied to each eye up to six times daily 3
  • Continue until resolution of discharge

For suspected chlamydial conjunctivitis:

• Systemic therapy:

  • Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days 1
  • This is essential as topical therapy alone is ineffective for chlamydial infection

• Topical therapy:

  • Erythromycin ophthalmic ointment as adjunctive treatment 2

Timing Considerations

The timing of symptom onset helps determine the likely pathogen:

• Gonococcal conjunctivitis typically presents 1-7 days after birth
• Chlamydial conjunctivitis typically presents 5-19 days after birth 2

Since this infant is 3 days old with purulent discharge and chemosis, gonococcal infection is highly suspected and should be treated aggressively.

Follow-Up Care

1. Monitor response to treatment:

   • Clinical improvement should occur within 24-48 hours
   • If no improvement after 48-72 hours, reassess diagnosis and treatment 1

2. Evaluate and treat the mother and her sexual partner(s):

   • Both gonococcal and chlamydial infections in neonates indicate maternal infection
   • Testing and treatment of the mother and her partner(s) is essential to prevent reinfection 1

3. Consider additional testing:

   • For gonococcal infection: blood cultures to rule out systemic infection
   • For chlamydial infection: monitor for development of pneumonia (staccato cough, tachypnea) 1

Important Caveats

1. Topical antibiotic therapy alone is inadequate for both gonococcal and chlamydial conjunctivitis in neonates 1, 2

2. Erythromycin prophylaxis at birth would not have prevented chlamydial conjunctivitis with high certainty, as studies show similar rates of chlamydial conjunctivitis regardless of prophylaxis 4, 5

3. Watch for complications:

   • Gonococcal: corneal ulceration, perforation, and systemic infection
   • Chlamydial: pneumonia developing at 1-3 months of age 1

4. The efficacy of erythromycin treatment for chlamydial infection is approximately 80%, so a second course may be needed if symptoms persist 1

This aggressive approach is necessary because untreated gonococcal conjunctivitis can rapidly lead to corneal perforation and blindness, while chlamydial infection can cause pneumonia and other systemic complications.