What is the recommended use of erythromycin (antibiotic) ointment in newborns?

Erythromycin Ophthalmic Ointment for Newborns

Erythromycin 0.5% ophthalmic ointment should be applied as a single application to both eyes of all newborns as soon as possible after delivery for the prevention of ophthalmia neonatorum. 1, 2

Recommended Prophylaxis Protocol

• Erythromycin 0.5% ophthalmic ointment is the only FDA-approved medication for neonatal ocular prophylaxis in the United States 1
• A ribbon of ointment approximately 1 cm in length should be instilled into each lower conjunctival sac 2
• Application should occur as soon as possible after birth, regardless of whether delivery is vaginal or cesarean 1
• The ointment should not be flushed from the eye following instillation 2
• A new tube should be used for each infant to prevent cross-contamination 2
• If prophylaxis is delayed (not administered in the delivery room), a monitoring system should be established to ensure all infants receive prophylaxis 1

Purpose and Efficacy

• Ocular prophylaxis is primarily effective in preventing gonococcal ophthalmia neonatorum, which can cause corneal scarring, ocular perforation, and blindness if left untreated 1
• Gonococcal ophthalmia develops in approximately 28% of newborns delivered to women with gonorrheal disease 1
• While erythromycin ointment is effective against gonococcal ophthalmia, its efficacy in preventing chlamydial ophthalmia is less clear 1
• Evidence suggests erythromycin may be more effective than silver nitrate in preventing chlamydial conjunctivitis 3
• Moderate-certainty evidence indicates that prophylaxis likely reduces the risk of conjunctivitis of any etiology in the first month of life 4

Important Considerations

• Ocular prophylaxis is required by law in most states 1
• For infants born to mothers with clinically apparent gonorrhea, erythromycin ophthalmic ointment alone is inadequate - these infants should also receive systemic treatment with intravenous or intramuscular aqueous crystalline penicillin G (50,000 units for term infants or 20,000 units for low birth weight infants) 2
• Prophylaxis does not eliminate nasopharyngeal colonization by Chlamydia trachomatis 1
• The best method for preventing neonatal gonococcal and chlamydial disease is diagnosis and treatment of these infections in pregnant women, but not all women receive prenatal care 1

Adverse Effects

• Very low-certainty evidence suggests no increased risk of nasolacrimal duct obstruction or keratitis with prophylaxis 4
• Chemical conjunctivitis is more commonly associated with silver nitrate than with erythromycin 5

Alternative Prophylactic Agents

• Tetracycline 1% ophthalmic ointment was previously recommended but is no longer available in the United States 1
• Silver nitrate 1% solution was historically used but is associated with chemical conjunctivitis and is less commonly used now 5
• Povidone-iodine 2.5% has been studied but is not FDA-approved for this indication in the United States 1

The universal application of erythromycin ophthalmic ointment to all newborns represents a safe, effective, and inexpensive intervention to prevent potentially sight-threatening gonococcal ophthalmia neonatorum 1.