Ophthalmia Neonatorum: IAP Guidelines

Written by Ayesha Published On 2023-04-24T10:00:45+05:30 | Updated On 24 April 2023 10:04 AM GMT

Ophthalmia neonatorum refers to any conjunctivitis occurring in the first 28 days of life. It can be a sight-threatening condition of the eye seen in the first 4 weeks of life. Reported incidence in India is 0.5–33%.The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Ophthalmia Neonatorum. The lead author for these guidelines on Ophthalmia...

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Ophthalmia Neonatorum. The lead author for these guidelines on Ophthalmia Neonatorum is Dr. Arvind Shenoi along with co-author Dr. Tunu Gadi and Dr. Sachin Shah. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:

Etiology:

Source:Indian Academy of Pediatric Guidelines

Signs and Symptoms:

TABLE 1: Signs and symptoms of ophthalmia neonatorum.
*Causative agent*	*Signs and symptoms*	*Time of appearance*	*Special consideration*
Chlamydia trachomatis (chlamydial ophthalmia)	Minimal mucopurulent discharge to severe eyelid edema with copious discharge and pseudomembrane formation	5–14 days after birth	Most common cause of late onset conjunctivitis Maternal cervix or urethra serves as reservoir of the organism Chlamydia pneumonitis may accompany neonatal conjunctivitis
Neisseria gonorrhoeae (gonococcal ophthalmia)	Severe eyelid edema, profuse mucopurulent discharge, chemosis, corneal ulceration, and blindness, if untreated	2–5 days after birth, earlier in premature rupture of membrane	Most virulent infectious cause of ophthalmia neonatorum
Chemical	Mildly red eye with some swelling of eyelids following topical prophylaxis	6–8 hours after instillation of topical prophylaxis	Disappears spontaneously after 48 hours
Herpes simplex (herpetic keratoconjunctivitis)	Red eye, serosanguinous discharge, vesicles on lid margin or skin, and hazy cornea due to edema Presence of dendritic keratitis is pathognomonic	Appears anytime during the first 2 weeks of life	Rare cause. Can be associated with generalized herpes simplex infection
Pathogenic bacteria Coagulase-negative Staphylococcus Alpha-hemolytic Streptococcus Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Pseudomonas species Escherichia coli species	Conjunctival redness and discharge	Within 72 hours of birth	Most common cause of conjunctivitis Occurs in vaginal deliveries Premature rupture of membranes is a risk factor Midwife examination is another risk factor

Evaluation:

Complete history:

• History of time of appearance of symptoms and signs

• History of risk factors, e.g., maternal sexually transmitted disease (STD), premature rupture of membrane, prolonged delivery, midwife interference, and unclean vaginal examination.

Examination:

• Conjunctivitis (discharge, edema/erythema of lids, and conjunctival hyperemia)

• Discharge (purulent in bacterial, watery or serosanguinous in viral, and greenish in Pseudomonas infection)

• Unilateral eye involvement in Staphylococcus aureus, Pseudomonas, and viral conjunctivitis

• Red reflex

• Systemic examination—look for systemic sepsis, abscess, cellulitis, and disseminated infection.

Eye discharge Gram stain and culture in Thayer Martin media and chocolate agar for bacteria, especially if gonococcal ophthalmia is suspected.

Conjunctival scraping polymerase chain reaction (PCR), Giemsa staining, or direct fluorescent antibody staining for chlamydial ophthalmia.

Conjunctival swab PCR for suspected herpetic infection. Blood and cerebrospinal fluid (CSF) analysis to exclude central nervous system (CNS) and disseminated disease.

Management:

If there is a high degree of suspicion of ophthalmia neonatorum but lack of confirmatory test, start treatment for both chlamydial and gonococcal ophthalmia to prevent sight-threatening complications (Table 2).

TABLE 2: Treatment for ophthalmia neonatorum.

Organism

First choice

Adjunct

Special considerations

Gonococcal

As per WHO STI guidelines Single dose of ceftriaxone injection IM 50 mg/kg/day (maximum 150 mg)

Kanamycin 25 mg/kg (maximum 75 mg) IM single dose

Spectinomycin 25 mg/kg

(maximum 75 mg) IM single dose

Normal saline irrigation of eyes every 1–2 hours Topical antibiotic not necessary

Isolate baby during first 24 hours of parental antibiotic therapy
Consider treating for chlamydia due to high rate of concomitant infection
Evaluate for disseminated disease
Test for other STD
Take ophthalmology consultation

*Organism*	*First choice*	*Adjunct*	*Special considerations*
Chlamydial	As per WHO STI guidelines Azithromycin 20 mg/kg once daily for 3 days is preferred over erythro- mycin 50 mg/kg/day orally in four divided doses for 2 weeks	Frequent normal saline irrigation of eyes	Neonatal prophylaxis with topical antibiotics do not prevent chlamydial ophthalmia For infants born to mothers with chlamydia exposure, educate family to monitor baby for infection including pneumonia
Herpetic	Parenteral acyclovir 20 mg/kg three times a day for 14 days (21 days if disseminated or CNS disease) along with topical ganciclovir 0.15% or 1% trifluridine five times a day for 10–14 days		Seek ophthalmology consultation. Keratitis, retinopathy and chorioretinitis can develop Evaluate and treat for systemic herpes Isolate baby
Coagulase-negative Staphylococcus Alpha-hemolytic Streptococcus Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Pseudomonas species Escherichia coli species	Ophthalmic drops— tobramycin or gentamicin × three to four times a day × 7 days		Most common cause of conjunctivitis Occurs following vaginal delivery

(CNS: central nervous system; STD: sexually transmitted disease; STI: sexually transmitted infection)

Prevention for Ophthalmia Neonatorum:

Prophylaxis:

Silver nitrate prophylaxis for gonococcal ophthalmia neonatorum has been recommended in areas where incidence of maternal gonorrhea infection is high.

1% silver nitrate solution (Credé's method), 0.5% erythromycin ointment, 1% tetracycline hydrochloride, chloramphenicol 1% eye ointment, or 2.5% povidone iodine (aqueous solution without alcohol) is used for prophylaxis

However, it is not practiced in most parts of our country; the WHO STI guidelines 2017 recommend ocular prophylaxis for prevention of chlamydia and gonococcal infection. This guideline suggests one of the above-mentioned agents for topical application to both eyes immediately after birth.

Administration of colostrum into the eye has been shown in a small study to reduce the incidence of neonatal conjunctivitis.

Avoid cross contamination by frequent hand washing.

Avoid eye patching.

Chemical conjunctivitis resolves spontaneously. May need artificial tears.

Reference:

American Academy of Pediatrics. Gonococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds). Red Book: 2018 Report of the Committee on Infectious Diseases, 31st edition. Itasca, IL: American Academy of Pediatrics; 2018. pp. 355.
Ghaemi S, Navaei P, Rahimirad S, Behjati M, Kelishadi R. Evaluation of preventive effects of colostrum against neonatal conjunctivitis: a randomized clinical trial. J Educ Health Promot. 2014;3:63.
Kapoor VS, Evans JR, Vedula SS. Intervention for preventing ophthalmia neonatorum. Cochrane Database Syst Rev. 2020;9(9):CD001862.
Mammooty NC, George M, Joseph J, Tawab A. Proportion of ophthalmia neonatorum following prophylaxis with azithromycin eye ointment in newborns at a tertiary care centre in Central Kerala. Int J Contemp Pediatr. 2021;8(10):1720-4.
Wadhwani M, D'Souza P, Jain R, Dutta R, Saili A, Singh A. Conjunctivitis in newborn—a comparative study. Ind J Pathol Microbiol. 2011;54(2):254-7.
World Health Organization. WHO Recommendations on Newborn Health: Guidelines Approved by the WHO Guidelines Review Committee. Geneva: World Health Organization; 2017.
Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of neonatal chlamydial conjunctivitis: a systematic review and meta-analysis. J Pediatric Infect Dis Soc. 2018;7(3):e107-15.

The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/

Indian Academy of PediatricIAP GuidelinesOphthalmia NeonatorumserosanguinousSTDgonococcalconjunctivitis

Source : Indian Academy of Pediatric, IAP Guidelines

Ayesha

Ayesha has completed B.pharma from the United Institute of Pharmacy and currently pursuing a pharmaceutical MBA from Jamia hamdard. She is working as an intern with Medical Dialogue.

More News