Which of the following is are the most common cause s of neonatal conjunctivitis?
Synonym: conjunctivitis of the newborn, neonatal conjunctivitis Show
Definition and aetiology[1, 2]Ophthalmia neonatorum (ON) refers to any conjunctivitis occurring in the first 28 days of life. Originally, the term neonatal ophthalmia referred to conjunctivitis in the newborn caused by Neisseria gonorrhoeae, but now the term is used for any conjunctivitis in this age group, irrespective of cause. It is most commonly infective in origin. N. gonorrhoeae was the most common cause of infective ON in the past, but now accounts for less than 1% of reported cases in the UK. Chlamydia trachomatis took over as the most common single cause of infective neonatal conjunctivitis. However, incidence of both these pathogens has declined over recent decades, due both to decreased prevalence in the population and to the introduction of prenatal screening, although they are much more common in less developed countries. Non-sexually transmitted bacteria, such as Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas and Haemophilus species and other Gram-negative bacteria, make up most of the remaining ophthalmia neonatorum cases (30-50%). Viral infections are less common and can be caused by herpes simplex virus, adenovirus or enterovirus. It may also occur as a reaction to chemical irritants, in particular silver nitrate, which has been used for prophylaxis in the past in the UK, and still is in many other countries. In most cases ophthalmia neonatorum is a mild illness. Untreated infection, however, particularly gonococcal infection, can progress rapidly to corneal damage and permanent visual impairment. As of April 2010, ophthalmia neonatorum is no longer a notifiable disease in the UK[3]. Epidemiology[2]Prevalence varies significantly in different parts of the world, depending on socio-economic status, standards of maternal healthcare and prevalence of sexually transmitted infections. An analysis in England of hospital episode statistics from 2000 to 2011 in England found the incidence rate of hospitalised cases of ophthalmia neonatorum to be 257 per 100,000 live births in 2011[4]. In 2003, incidence of chlamydia-induced ON was 6.9 per 100,000 live births, and of ON caused by gonorrhoea, 3.7 per 100,000 live births. Incidence of chemical conjunctivitis is higher in countries that use prophylaxis, but decreasing as silver nitrate prophylaxis is being replaced by other agents (see 'Prevention', below) which in turn, have significantly reduced the incidence of gonococcal conjunctivitis. In the past, ophthalmia neonatorum has been one of the most common causes of visual loss, reportedly accounting for 45% of blindness in Paris, and up to 80% in blind institutions in Germany in the late 1800s[5]. These types of figures have reduced worldwide, but the condition remains an important cause of loss of sight in developing countries. The main risk factor for ophthalmia neonatorum of gonococcal or chlamydial origin is the presence of a sexually transmitted disease in the mother. There is a high rate of transmission (30-50%) from infected mother to infant. PresentationAffected babies present with a purulent, mucopurulent or mucoid discharge from one or both eyes within the first month of life. They typically show injected conjunctiva and lid swelling. There may be associated systemic infection. Chemical conjunctivitisThere is a mild irritation, tearing and redness in a baby who has been administered prophylactic silver nitrate (used for the prevention of gonorrhoeal infection) within the preceding 24-48 hours. Bacterial conjunctivitisThis usually (but not invariably) has a longer incubation period than for the other infective causes, presenting with a subacute onset between the 4th and 28th day of life. Depending on the pathogen, there may be a mixed picture of a red eye with lid swelling and a varying amount of purulent discharge. Specific common types of bacterial infection are:
Viral conjunctivitisOnset is acute, 1-14 days after birth: unilateral/bilateral serosanguinous discharge ± vesicular skin lesions. Other ocular features may include keratitis, anterior uveitis, cataract, retinitis and (rarely) optic neuritis. Uncommonly, systemic infection can cause jaundice, hepatosplenomegaly, pneumonitis, meningoencephalitis and disseminated intravascular coagulation. Differential diagnosisA blocked nasolacrimal duct is common and results in a thick (sometimes copious) discharge which may be sticky or crusty. The eye is not red and the baby is otherwise well. The discharge may be intermittent and responds well to simple cleansing. Most babies' ducts clear as they grow, the majority functioning normally by 12 months of age. In the UK a blocked nasolacrimal duct is more likely to be the cause of sticky eyes in newborns presenting to GPs. This does not usually result in the conjunctiva being red or the eyelids being swollen. Refer all newborns with red and sticky eyes[6]. Investigations[7, 8]For the GP: as above, a neonate with red and sticky eyes or with very profuse discharge or swollen eyelids/surrounding cellulitis should be referred immediately for specialist assessment. In the absence of red flags, a baby under a month old with sticky eyes not being referred should have swabs taken of the pustular material for bacterial culture and for chlamydia. Some laboratories can do a combined molecular test for gonorrhoea and chlamydia (nucleic acid amplification test ( NAAT)). The purpose of the test must be explained to the parent(s) as there may be implications for the parents should it prove positive. For a specialist eye unit: other aspects of investigation in a specialist eye unit under consultant direction include:
Management[9, 10]ReferralThe majority of neonates presenting with a sticky discharge have a benign cause - most frequently due to blocked nasolacrimal duct(s). Features suggesting that referral is necessary are those suggestive of possible gonococcal involvement, and include:
If you suspect gonococcal infection, refer immediately. Early and appropriate treatment have long been recognised as the key to preventing consequent severe sight impairment. In summary, for a GP seeing a baby under the age of 1 month with sticky eyes: if the eyes are red as well as sticky, or if any of the other concerning features are present, refer for specialist advice immediately. If there are no concerning features then take swabs for bacterial culture, gonorrhoea and chlamydia. Treatment of ophthalmia neonatorum is managed by a specialist. Initial therapyDepending on the assessed risk (from signs, history, local prevalence), prior to results from Gram staining (or if these are inconclusive), it may be appropriate to start the infant on a broad-spectrum antibiotic or treatment for both chlamydia and gonorrhoea until the microbiological results have come back. If the initial infection recurs, chlamydia should be reconsidered (even if the baby first tested negative), as this organism is difficult to demonstrate in the laboratory and can be missed. Chemical conjunctivitisThis is a self-limiting condition. No treatment is required, although some favour the use of preservative-free artificial tears qds. These babies need early review (24 hours) to confirm that this was indeed a case of chemical irritation as opposed to early infection. Bacterial infectionTreatment should be guided by the organism grown. If there is corneal involvement, the baby may be hospitalised and treated as for microbial keratitis. Chlamydial infection[11] Gonorrhoeal
infection[12] Other bacterial
infections Viral infectionThese babies should be hospitalised and treated with IV aciclovir (full-term infants: 45-60 mg/kg/day in divided doses. This is continued for 14 days if there is limited disease and 21 days if there is disseminated disease, which can be devastating) in addition to topical antiviral preparations. ComplicationsThe complications mainly relate to gonococcal conjunctivitis. Most other causes of conjunctivitis in the newborn are fairly benign. Gonococcal complications include:
Other bacteria can (rarely) have serious consequences:
Prognosis
PreventionPrenatal maternal screening and treatment for sexually transmitted infections is the best method of prevention of this condition[11]. In some countries, prophylactic treatment for neonates is still routine, although this was abandoned in the UK in the 1950s. Traditionally, this has involved the use of 2% silver nitrate ophthalmic solution. More recently topical erythromycin has been used more commonly, as it is less likely to cause transient chemical conjunctivitis and is considered slightly more effective[13]. Tetracycline drops are also used[10]. Prophylaxis is required by law in many parts of the USA and Canada[12, 14]. Topical prophylaxis is not effective in preventing ON due to chlamydial infection. What is the most common cause of neonatal conjunctivitis?Conjunctivitis in a newborn may be caused by a blocked tear duct, irritation produced by the topical antimicrobials given at birth, or infection with a virus or bacterium passed from the mother to her baby during childbirth.
What are the 3 causes of conjunctivitis?The three most common causes of this inflammation are: infection (infective conjunctivitis) an allergic reaction (allergic conjunctivitis) something irritating the conjunctiva, such as a loose eyelash (irritant conjunctivitis)
Which one is the most common cause of ophthalmia neonatorum?Chlamydia is the most common infectious agent that causes ophthalmia neonatorum in the United States, where 2% to 40% of neonatal conjunctivitis cases are caused by Chlamydia.
What are the 2 causes of ophthalmia neonatorum?The definition of Ophthalmia Neonatorum (conjunctivitis of the newborn) is an eye infection that occurs within the first 30 days of life. It is caught during birth by contact with the mother's birth canal that is infected with a sexually-transmitted disease. The infection may be bacterial, chlamydial or viral.
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