2. Neonatal Conjunctivitis Or Ophthalmia Neonatorum S. Ghaemi.MD Neonatal Conjunctivitis Or Ophthalmia Neonatorum S. Ghaemi.MD

3. Conjunctivitis is the most common ocular diseases in neonates and the prevalence rate in the world is about 20% and in the united states is 2%.

4. Etiology : 1.Chemical 2.Chlamydial 3.Bacterial 4.Viral

5. Time of presentation according to etiology of conjunctivitis Time of presentation Etiology 6-12 H 5 days – 2 weeks 5 days – 3 Weeks 2 days – 2 weeks 2 days – 5 days Chemical conjunctivitis Chlamydia conjunctivitis Bacterial conjunctivitis: S. Aureus H. Influenza S. Pneumonia Herpes simplex N. Gonorrhoeae

6. Chlamydia trachomatis (Inclusion blennorrhea) C. trachomatis infection is the most common form of ophthalmia neonatorum today. Occurring in up to 1% of births in developed countries.

7. Is primarily transmited to newborn via exposure to an infected mother’s genital flora during vaginal birth and it causes neonatal conjunctivitis between 20-50% and pneumonia about 10-20%.

8. Clinical manifestations The incubation period is 5-14 days after delivery. Presentation occurs earlier in PROM Clinical findings range from→ mild swelling with a watery eye discharge → to marked swelling of eyelids witch becomes mucopurulent and usually are bilateral. Untreated patient may persist for months and cause corneal and conjunctival scarring.

9. Diagnosis : 1.Culture → by conjunctival scrapings 2.Non culture methods for detection of chlamydial antigens: A. Direct fluorescent antibody B. Enzyme linked immunosorbent assay (ELISA) C. DNA probe D. Optical immunoassay (OIA) E. Polymerase chain reaction (PCR)

10. Treatment : Erythromycin (50 mg/kg/day/qid/2weeks/po) some patient needs second course of treatment. Ethylsuccinate (50 mg/kg/day/qid/2weeks/po) Oral erythromycin may causes → infantile hypertrophic pyloric stenosis in infants less than 6 weeks of age.

11. Topical treatment is unnecessary Azithromycin (20 mg/kg po) may be effective. Sulfisoxazole (150 mg/kg/day/qid/po) after neonatal period.

13. Gonococcal infection The eye is the most frequent site of gonococcal infection in the newborn. It causes a purulent conjunctivitis, with profuse exudates and swelling of the eyelids. Without treatment, it causes blindness. The incubation period is 2-5 days after birth and it occurs earlier in presence of PROM.

14. Diagnosis Newborns who develop conjunctivitis after the first day of age or appear to have severe or persistent chemical conjunctivitis should be evaluated.

15. Gram stain → conjunctiva exudates for the presence of gram- negative intracellular kidney bean shaped diplococci. Culture → exudates on Thayer – Martin medium, should be performed. If organisms are detected, anal and oropharyngeal culture should be obtained. Co infection with C. trachomatis is common.

16. Infant should be hospitalized. Treatment with singele dose of ceftriaxone (25-50 mg/kg/not to exceed 125 mg/Iv or IM). Topical antibiotic therapy alone is inadequate and is not necessary. The eyes should be irrigated with saline. Treatment.

17. Infants of untreated mothers: Treatment of symptomatic infants whose mothers have untreated gonococcal infection → single dose of ceftriaxone (25-50 mg/kg/ up to a total dose of 125 mg/Iv or IM) and also should be evaluated for chlamydial infection.

18. Prevention: The following are regimens recommended by the AAP. 1.Silver nitrate (1%) aqueous solution. 2.Erythromycin (0.5%) ophthalmic ointment. 3.Tetracycline (1%) ophthalmic ointment. 4.Povidone – iodine (2.5%) → more effective prophylaxis for chlamydia.

19. Maternal screening : Pregnant women should be screened for N. gonorrhoeae and C. trachomatis as part of routine prenatal care. High-risk women or women without prenatal care should be screened at delivery.

21. Other localized infection: Localized infection, such as pharynx, vagina, urethra, and anus can be affected. Treatment, as in the case of ophtalmia neonaterum (single dose of ceftriaxone 25-50 mg/kg).

22. Disseminated infection: Septic arthrits, gonoccal bacteremia and meningitis are rare in the newborn but can be a complication of opthalmia neonatorum.

23. Culture should be obtained of blood and CSF and from an affected joint. Treatment for bacteramia and septic arthritis with ceftriaxone (25-50 mg/kg/per dose) IV or IM for 7 days, and 10-14 days for meningitis.

25. Other bacterial conjunctivitis : 1.S. aurous 2.E. coli 3.Hemophilus influenzae 4.Pseudomonas aeruginosa

26. Treatment with local opthalmic ointments (erythromycin or gentamicin) are effective, without complication. Pseudomonas aeruginosa → require parenteral treatment with an aminoglycosid. + an antipseudomonal penicillin in addition to topical treatment is indicated. Very severe cases caused by H. influenza may require parenteral treatment. Treatment.

28. Nasolacrimal obstructions :  The distal end of the nasolacrimal duct frequently is imperforate at birth.  Subsequent infection → purulent discharge and tearing.  In most cases the infection is alleviated by → opening of the occluded duct by 7 months of age.

29. Treatment → the opening may occur spontaneously/or → by digital massage over the duct + antibiotic eye drop. Therapy with ophtalmic ointment may only furthe occlude the duct.

30. When the symptoms persist beyond 6 – 7 months of age → probing of the duct is indicated → the success rate is > 90% Persistent obstruction → the probing repeated.

32. Omphalitis Omphalitis is characterized by erythema and/or induration of the periumbilical area with purulent discharge and some time foul smelling from the umbilical stump.

33. Complication Abdominal wall cellulitis Necrotizing facities Peritonitis Umbilical arthritis/phlebitis Hepatic vein thrombosis/hepatic abscess

34. Etiology: Organisme that are found on the skin. Or introduced into the umbilical vessel by catheterization. S. aureus and E. coli are frequent pathogens. Other bacteria, goroup A streptococci Anaerobic bacteria.

35. Diagnosis: gram-stained and culture of purulent material and a full sepsis evaluation (CBC-BC-LP).

36. Treatment : Otherwise well-appearing infants with → moist or smelly cords without periumbilical erythema edema, or exudate → local treatment.

37. Infants with periumbilical erythema, edema, and tenderness with or without purulent drainage need parenteral administration of antibiotics. Oxacillin or nafcillin and gentamicin IV

38. With serious disease progression → cephalosporin or piperacillin. The presence of crepitus or black discoloration of the periumbilical tissue caused by anaerobic or mixed infection → adding metronidazole or clindamycin.