What is the diagnosis and management of ophthalmia neonatorum in a newborn?

Ophthalmia Neonatorum: Diagnosis and Management

Immediate Diagnostic Approach

When evaluating a newborn with eye discharge or conjunctivitis in the first 28 days of life, immediately obtain conjunctival exudate for Gram stain and culture for both N. gonorrhoeae and C. trachomatis before initiating treatment. 1

Key Diagnostic Features by Timing and Pathogen

• Gonococcal ophthalmia typically manifests 2-5 days after birth as acute purulent conjunctivitis with intracellular gram-negative diplococci on Gram stain 1
• Chlamydial conjunctivitis develops 5-12 days after birth and is the most frequent identifiable infectious cause of ophthalmia neonatorum 1
• Specimens must contain conjunctival cells (not exudate alone) obtained from the everted eyelid using a dacron-tipped swab 1
• Culture on chocolate agar for N. gonorrhoeae with antibiotic susceptibility testing is mandatory due to public health implications 1

High-Risk Indicators

• Infants who did not receive ophthalmia prophylaxis at birth 1
• Mothers with no prenatal care, history of STDs, or substance abuse 1

Management of Gonococcal Ophthalmia Neonatorum

Treat with ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg, and hospitalize the infant immediately for evaluation of disseminated infection. 1

Critical Management Steps

• Hospitalize all infants with gonococcal ophthalmia and evaluate for sepsis, arthritis, and meningitis 1
• One dose of ceftriaxone is adequate therapy for gonococcal conjunctivitis alone 1
• Topical antibiotic therapy alone is inadequate and unnecessary if systemic treatment is administered 1
• Administer ceftriaxone cautiously to hyperbilirubinemic infants, especially premature newborns 1

Concurrent Chlamydial Infection

• If the infant does not improve after gonococcal treatment, simultaneous C. trachomatis infection must be considered 1
• Test both mother and infant for chlamydial infection at the same time as gonorrhea testing 1

Management of Chlamydial Ophthalmia Neonatorum

Treat with erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses daily for 14 days. 1, 2

Treatment Efficacy and Follow-up

• Erythromycin treatment efficacy is approximately 80%; a second course may be required 1
• Follow-up is mandatory to determine whether treatment was effective 1
• Topical antibiotic therapy alone is inadequate and unnecessary when systemic treatment is administered 1
• Evaluate for concomitant chlamydial pneumonia (presents at 1-3 months with staccato cough and tachypnea) 1

Diagnostic Confirmation

• Use tissue culture or nonculture tests (direct fluorescent antibody, enzyme immunoassays, nucleic acid amplification tests) 1
• Specimens must contain conjunctival cells obtained from everted eyelid 1
• Test ocular exudate for N. gonorrhoeae simultaneously 1

Management of Mothers and Sexual Partners

The mothers of all infants with gonococcal or chlamydial ophthalmia and their sex partners must be evaluated and treated according to adult STD treatment guidelines. 1

• For pregnant women with chlamydial infection, azithromycin 1 g orally as a single dose is first-line treatment 3
• Alternative regimens include amoxicillin 500 mg orally three times daily for 7 days or erythromycin base 500 mg orally four times daily for 7 days 3, 2
• Doxycycline and quinolones are absolutely contraindicated in pregnancy 3

Prophylaxis Considerations

Universal neonatal ocular prophylaxis prevents gonococcal ophthalmia but does not prevent chlamydial transmission from mother to infant. 1

• Prophylaxis with tetracycline 1%, erythromycin 0.5%, povidone-iodine 2.5%, or silver nitrate 1% probably reduces conjunctivitis of any etiology (moderate-certainty evidence) 4
• Prenatal screening and treatment of pregnant women is the most effective preventive strategy for chlamydial infection 3
• Evidence does not suggest any consistently superior prophylactic agent 4

Critical Pitfalls to Avoid

• Never rely on topical therapy alone for either gonococcal or chlamydial ophthalmia—systemic treatment is mandatory 1
• Do not discharge infants with gonococcal ophthalmia without hospitalization and evaluation for disseminated disease 1
• Do not assume treatment success with chlamydial infection—follow-up is essential as 20% may require retreatment 1
• Remember that Moraxella catarrhalis and other Neisseria species are indistinguishable from N. gonorrhoeae on Gram stain but can be differentiated by culture 1
• Always test for both pathogens simultaneously, as co-infection is common 1