REVIEW ARTICLE

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NEONATAL CONJUNCTIVITIS – A REVIEW

PS Mallika¹, MS; T Asok², MMed; Faisal HA², MS; S Aziz², MS; AK Tan¹, MD; G Intan², MS.

¹Department of Ophthalmology, Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Kuching, Sarawak, Malaysia (Mallika Premsenthil)
²Department of Ophthalmology, Sarawak General Hospital, Kuching, Sarawak, Malaysia (Asokumaran Thanaraj, Humayun Akter Faisal, Mohamad Aziz Salowi, Tan Aik Kah, Intan Gudom)

Address for correspondence: Dr. Mallika Premsenthil, Lecturer, Ophthalmology unit, Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Lot 77, Sekysen 22 Kuching Town Land District, Jalan Tun Ahmad Zaidi Adruce, 93150 Kuching, Sarawak, Malaysia. Tel: +6082-416550, Fax: + 6082-422564, Email: pmallika@fmhs.unimas.my

Conflict of interest: None

INTRODUCTION

Neonatal conjunctivitis is often known as ophthalmia neonatorum (Latin name). It is defined as conjunctivitis occurring in a newborn during the first month of life with clinical signs of erythema and oedema of the eyelids and the palpebral conjunctivae, purulent eye discharge with one or more polymorph nuclear per oil immersion field on a Gram stained conjunctival smear.¹  Originally described in 1750, it is one of the most common infections occurring in the first month of life.²

Ophthalmia neonatorum leads to blindness in approximately 10,000 babies annually worldwide.³ The major causes of Ophthalmia neonatorum are, in decreasing order, chemical inflammation, bacterial infection and viral infection. The majority of infectious neonatal conjunctivitis are due to bacteria.⁴ The bacterial causes include sexually transmitted diseases agents (Chlamydia trachomatis and Neisseria gonorrhoea), microorganisms from the skin (Staphylococcus aureus) and the mother’s gastrointestinal tract (Pseudomonas sp).⁵ The  inflammation usually resolves spontaneously within a few days. Therefore, simple Gram stain and routine bacterial culture are often the only investigations that are required in most cases.⁶ Although simple investigation suffices, treatment has to be adequate because systemic complication and severe visual loss can occur in infection particularly with Chlamydia trachomatis and Neisseria gonorrhoea.⁷ Apart from bacteria, herpes viruses can also cause neonatal conjunctivitis.

The organisms causing neonatal conjunctivitis are usually acquired from the infected birth canal of the mother, though some may acquire the infection from their immediate surroundings.⁸ The predisposing factors, which can increase the chance of the newborn acquiring neonatal conjunctivitis, include increase shedding of these organisms in the vaginal tract of the mother during the last trimester, premature rupture of membranes and prolonged labor. Neonatal conjunctivitis following caesarean section could be due to intrauterine chlamydial infection as the result of early rupture of the membranes⁸ or trans-placental or transmembrane transfer of these organisms.⁹

The epidemiology of Ophthalmia Neonatorum has changed following the prophylactic use of 1% silver nitrate solution (Crédé method); there was a marked reduction in the incidence of ophthalmia in the United States, Europe, and the United Kingdom following the widespread application of the Crédé prophylaxis.¹⁰ However, the role of silver nitrate prophylaxis is only to prevent ophthalmia due to gonococcal infections; it is not effective against Chlamydia. Silver nitrate prophylaxis is not used currently due to the ineffectiveness in preventing chlamydial infection and the tendency to cause chemical conjunctivitis. This method of prophylaxis has been replaced by the use of erythromycin or tetracycline ointment.¹¹

EPIDEMIOLOGY

Ophthalmia neonatorum is a worldwide problem. The pathogens responsible for causing the infection vary geographically due to the differences in the prevalence of maternal infection and the prophylactic use of antibiotics and silver nitrate solution.² In the developed world, Chlamydia has been reported as the most common infectious agent responsible for ophthalmia compared to gonococcus. However in developing nations, both chlamydial and gonococcalinfections are prevalent. In Malaysia the incidence is significantly high due to lack of routine prophylactic measures and due to emergence of pencillinase-producing N. gonorrhoea (PPNG) strains. The actual incidence is unknown due to under-reporting. A study on gonococcal ophthalmia neonatorum in the state of Kelantan has shown an increase in the percentage of cases infected with penicillin resistant strains of N. gonorrhoea from 6.4% to 25.9%.¹² Lockie P et al ¹³ in their retrospective study involving 80 cases reported 7.5% due to PPNG.  The Pencillinase-producing strains are believed to originate from South-East Asian region namely from Bangkok where 48.9% of strains of N. gonorrhoea isolated were due to PPNG.¹⁴

The prevalence of ophthalmia due to gonococcal infection is reported to be 0.04 per 1000 live births in Belgium and Netherlands, and 0.3 per 1000 live births in the United States.^15,16 At the moment, Chlamydia trachomatis is the most frequent sexually transmitted pathogen in the developed nations with prevalence of 5 to 60 per 1000 live births in the United States, 4 per1000 live births in the United Kingdom and 40 per 100 live births in Belgium; whereas the prevalence of gonorrhoea among antenatal attenders in the African countries ranges from 4% to 15 %.¹⁷ Approximately 25% to 50% of infants exposed to Chlamydia trachomatis and Neisseria gonorrhoea develop neonatal conjunctivitis, without prophylaxis.¹⁸

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