Neonatal Conjunctivitis A review of pathology, treatment - PowerPoint Presentation

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Neonatal Conjunctivitis

A review of pathology, treatment options, patient disposition, and differential diagnosis.

Adrienne DePorre, MD

Pediatric Hospitalist

Children’s Mercy Kansas City

What patients are we talking about?

Infants <29 days of lifeWell appearing without concern for fever / temp instabilityHave both conjunctival injection/erythema AND purulent discharge or present with hemorrhagic ocular discharge

Nasolacrimal

duct obstruction vs. neonatal conjunctivitis

Neonatal Conjunctivitis Care Process Model

Team based approach: Infectious Disease, Ophthalmology, Emergency Department/Urgent Care, Hospitalists, Evidence-Based Medicine team. Combination of expert opinion, previously published evidence, and local dataIterative process

Aims to guide medical decision-making regarding clinical questions such as: which patients needs testing, what testing needs to be done, what are the best treatment options, patient disposition?

What organisms are we primarily concerned about?

Chlamydia Trachomatis (2 - 40%)Neisseria Gonorrhea ( < 1%)

Herpes Simplex Virus ( <1%)Other Bacterial Pathogens (30-50% of case):

Staph Aureus, Streptococcal Species, gram-negative bacteria, Haemophilus, Pseudomonas

Neisseria Gonorrhea

Typically presents with sudden, severe, grossly purulent conjunctivitis 2-5 days after birthSevere manifestations include conjunctivitis and sepsis (including arthritis and meningitis), with potential progression to blindness

Topical erythromycin ointment postnatally used as prophylaxis for GCWithout prophylaxis, 30-42% of infants born to infected mothers will develop GCwith prophylaxis, 10% still may develop GC conjunctivitis

Neonatal ocular prophylaxis currently under debate ( does not prevent against chlamydial infections)Rare: US prevalence reported as 0.3 cases per 1000 births

Gonorrhea Testing/Management

Conjunctivitis Testing:Obtain Gonorrhea culture of ocular specimen gold standard ( Thayer-Martin media /Chocolate Agar)

Does not grow well on typical aerobic culture mediumPCR for N Gonorrhea equal or superior to culture, but not FDA approved for eye surface useConcern for systemic Disease:Obtain Eye, Blood, CSF cultures

Management recommendations:Ophthalmology consult and exam in the ED or inpatient settingCeftriaxone 25-50 mg/kg IV or IM x 1 ( max 125 g) OR cefotaxime 100 mg/kg

Admission for further treatment and monitoring

Ophthalmic irrigations with sterile isotonic saline

ID consult if concerned for systemic disease

Chlamydia Trachomatis

Typically presents with erythema, edema of eyelids, palpebral conjunctivae and purulent eye drainage 5-14 days after birthComplications of delayed/untreated infection: corneal/conjunctival scarring, pneumonia.

Most common cause of neonatal conjunctivitis world-wide0.85 per 1000 births in the US ( 2002)30-50% of infants born to mothers with active chlamydia infection will develop conjunctivitisHong Kong Study- hemorrhagic eye discharge predictor for

C.Trachomatisnot backed by any other studies

Chlamydia Testing/Management

Conjunctivitis Testing:Chlamydia eye cultureCulture must contain epithelial cells ( C trachomatis is obligate intracellular organism)

PCR for Chlamydia equal or superior to culture, but not FDA approved for eye surface useManagement Recommendations: Azithromycin 20 mg/kg/day x 3 days - preferredErythromycin 50 mg/kg/day x 14 days

Management in outpatient setting with follow up with PCP or Ophthalmology in 48-72 hours.

Herpes Simplex Virus 1/2

HSV disease occurs in estimated 1/3200 neonates. Manifested as SEM, disseminated, CNS disease not mutually exclusiveIsolated conjunctivitis due to HSV is rare, but neonates at high risk for HSV should be evaluated for SEM, systemic/disseminated, and CNS disease

Suspect based on maternal history, vesicular lesions on exam

HSV Testing/Management

Conjunctivitis TestingViral culture or PCR of conjunctivaPCR FDA approved!

Evaluate for SEM, systemic and CNS diseaseHSV PCR from mouth, nasopharynx, anus and conjunctivaeHSV PCR from unroofed skin vesiclesLP with cell counts, protein, glucose, culture and HSV PCRSerum HSV PCR, liver enzymes

ManagementAcyclovir IV 20 mg/kg/dose q8 hrAdmit to hospital, recommend ID and ophthalmology consult

Differential Diagnosis

Nasolacrimal Duct Obstruction – No conjunctival injection/erythema, but does often have matting and discharge of the eye. Common congenital abnormality, incidence ranges from 6-20%

Cellulitis- preseptal or orbital cellulitis, facial cellulitis from odontogenic infectionDacryocystocele: bluish swelling of skin overlying lacrimal sack and superior displaced medial canthal tendon. Needs outpatient ophthalmology referral as infants at higher risk for complications such as

dacryocystitisDacryocystitis: infection of the nasolacrimal duct system – erythema, swelling, warmth, tenderness of lacrimal sac +/- purulent discharge.

Chemical Conjunctivitis

: within first 24 hours of life, more common previously with silver nitrate solution

Keratitis

- eye and sensitivity, no muco-purulent discharge. Could be from trauma, foreign body.

CMH ED/Urgent Care Order Set

Difficulties in Clinical Practice

Hard to differentiate causes of conjunctivitis based on clinical exam/timing alone. Obtain cultures on everyone with suspected neonatal conjunctivitis.Lessons learned: discuss appropriate culture/collection with local laboratory. Gonorrhea collection can be difficult to growProper bedside collection is key

Risk factors can help guide disposition and treatmentNeed to weigh risk of invasive testing/treatment vs. risks of inadequately treated diseaseTo LP or not to LP?Risk of systemic infection in Gonorrhea and HSV. Prior to giving systemic antibiotics, do we need to rule out meningitis?

Obtain cell counts after GC comes back positive?Need to make sure we can rely on GC culture

Local Data

Baseline (N=74)

Months 1-12 (N=51)

Months 13-24 (N=60)

Freq

Percent

Freq

Percent

Freq

Percent

Test for trend

Chlamydia

Tested

49

66.2%

38

74.5%

45

75.0%

0.2506

Positive

a

6

12.2%

3

7.9%

3

6.7%

0.3439

Gonorrhea

Tested

0

0.0%

40

78.4%

42

70.0%

<.0001

Positive

a

0

0.0%

0

0.0%

0

0.0%

---

Viral testing (e.g., HSV)

Tested

38

51.4%

24

47.1%

34

56.7%

0.5709

Positive

a

1

2.6%

0

0.0%

1

2.9%

0.9451

Aerobic culture not done

5

6.8%

23

45.1%

42

70.0%

<.0001

Used power plan

0

0.0%

23

45.1%

42

70.0%

<.0001

Invasive testing done

8

10.8%

4

7.8%

3

5.0%

0.2194

a

Among tested

References

Committee on Infectious Diseases. (2015). Red Book: Report of the Commitee on Infectious Diseases (2015)

(Kimberlin DW, Brady, MT, Jackson MA, & Long, SSEds. 30 ed.).Committee on Infectious Diseases. (2012). Red Book: Report of the Commitee on Infectious Diseases (Pickering LK, Baker CJ, Kimberlin DW, Long SS Eds. 29 ed.): American Academy of Pediatrics.

Chang, K., Cheng, V. Y., & Kwong, N. S. (2006). Neonatal haemorrhagic conjunctivitis: a specific sign of chlamydial infection. 

Hong Kong Med J, 12

(1), 27-32.

Hammerschlag

, M.R.,

Robilin, P.M., Gelling, M., Tsumura, N.,

Jule, J.E., & Kulten, A. (1997). Use of polymerase chain reaction for the detection of Chlamydia trachomatis in ocular and nasopharyngeal specimens from infants with conjunctivitis. Pediatric Infect Dis J, 16(3), 293-297Hammerschlag, M. R. (2011). Chlamydial and gonococcal infections in infants and children. Clin Infect Dis, 53 suppl 3, S99-102. doi:10.1093/cid/cir699

Hammerschlag, M. R., Gelling, M., Roblin, P. M., Kutlin, A., & Jule, J. E. (1998). Treatment of neonatal chlamydial conjunctivitis with azithromycin. Pediatr Infect Dis J, 17(11), 1049- 1050.Iroha, E. O., Kesah, C. N., Egri-Okwaji, M. T., &

Odugbemi, T. O. (1998). Bacterial eye infection in neonates, a prospective study in a neonatal unit. West Afr J Med, 17(3), 168-172. Johnson, R.E., Newhall, W.J., Papp, J.R., Knaoo, J.S., Black, C.M., Gift, T.L., . . . Berman, S.M. (2002). Screening tests to detect Chlamydia trachmotis and Neisseria gonorrhea infections—2002. MMWR Recomm Rep, 51(RR-15), 1-38; quiz CE31-34Laga

, M., Mähers, A., & Pilot, P. (1989). Epidemiology and control of gonococcal ophthalmia neonatorum. Bull World Health Organ, 67(5), 471-477.

References

MacDonald, N., Mailman, T., & Desai, S. (2008). Gonococcal infections in newborns and in adolescents. Adv Exp Med Biol, 609, 108-130. doi:10.1007/978-0-387-73960-1_9O'Hara, M. A. (1993). Ophthalmia neonatorum. 

Pediatr Clin North Am, 40(4), 715-725 Persson, K., & Ronnerstam, R. (1982). Neonatal eye infections caused by Chlamydia trachomatis. Scand J Infect Dis Suppl, 32

, 141-145.Rours, I. G., Hammerschlag, M. R., Ott, A., De Faber, T. J., Verbrugh, H. A., de Groot, R., & Verkooyen

, R. P. (2008). Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants. 

Pediatrics, 121

(2), e321-326. doi:10.1542/peds.2007-0153

Talley, A.R., Garcia-Ferrer, F., Laycock, K.A.,

Essary

, L.R., Holcomb, W.L., Jr., Flowers, B. E., . . .Pepose, j.S. (1994). Comparative diagnosis of neonatal chlamydial conjunctivitis by polymerase chain reaction and mcCoy cell culture. Am J Ophthalmol, 117(1), 50-57.Workowski, K.A., Bolan, G.A., Centers for Disease Control and Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. 

MMWR Recomm Rep, 64(RR-03), 1-137.Yip, T. P., W. H., Yip, K. T., Que, T. L., Lee, M. M., Kwong, N. S., & C. K. (2007). Incidence of neonatal chlamydial conjunctivitis and its association with nasopharyngeal colonisation in a Hong Kong hospital, assessed by polymerase chain reactiom Hong Kong MedJ, 13(1), 22-26.

Zuppa, A.A., D’Andrea, V., Catenazzi, P., Scorrano, A., & Romagnoli, C. (2011). Ophthalmia neonatorum: what kind of prophylaxis? J Matern Fetal Neonatal Med, 24 (6), 769-773. doin:10.3109/14767058.2010.531326

Thank you to Jeff Michaels MD ( Evidence-Based Practice, ED), Jackie Bartlett PhD ( Evidence-Based Practice), Christopher Day MD (Infectious Disease), Denise Hug MD ( Ophthalmologist), Brian Lee PhD ( statistical support)