Preventing ophthalmia neonatorum

Question 1

What is neonatal ophthalmia?

Answer 1

Conjunctivitis occurring within the first four weeks of life

Question 2

What percentage of neonatal ophthalmia is due to N gonorrhea?

Answer 2

<1%

Question 3

What percentage of neonatal ophthalmia is due to Chlamydia trachomatis?

Answer 3

2-40%

Question 4

What are the other causes of neonatal ophthalmia?

Answer 4

1. Staphylococcus species
2. Streptococcus species
   .
3. Hemophilus species
4. Other gram negative bacterial species
5. Viral infections (herpes simplex, adenovirus, enterovirus)

Question 5

What percentage of neonatal ophthalmia is due to other bacterial causes?

Answer 5

30-50%

Question 6

What are the complications of gonococcal ophthalmia?

Answer 6

1. Corneal ulceration
2. Perforation of the globe
3. Permanent visual impairment

Question 7

Without preventative measures what percentage of infants develop gonococcal ophthalmia in those exposed during delivery?

Answer 7

30-50%

Question 8

What is the Canadian resistance rate for erythromycin in N gonorrhea?

Answer 8

23%

Question 9

What other topical agents have been used historically for prevention of neonatal ophthalmia?

Answer 9

1. Silver nitrate (transient chemical conjunctivitis in 50-90% infants, no longer available)
2. Tetracycline (resistance 30%, no longer available)
3. Povidone-iodine (5% chemical conjunctivitis, maybe ineffective)
4. Gentamicin ointment (severe ocular reactions)

Question 10

What is the risk of acquiring infection in infants born to women with untreated chlamydia infection at delivery?

Answer 10

50% chlamydia

30-50% neonatal conjunctivitis

10-20% chlamydia pneumonia

Question 11

What is the effectiveness of topical ocular prophylaxis for chlamydia?

Answer 11

Does not prevent:

1. Transmission from mother to infant
2. Neonatal conjunctivitis
3. Pneumonia

Question 12

What is the complication of oral erythromycin use in infants?

Answer 12

Pyloric stenosis

Question 13

What are the recommendations regarding chlamydia?

Answer 13

1. Routine prenatal screening for C trachomatis
2. Treatment of identified infections during pregnancy
3. Close clinical f/u of exposed infants
4. Test conjunctival and nasopharyngeal secretions of symptomatic infants and treat those with positive results

Question 14

What are the CPS recommendations regarding neonatal ocular prophylaxis to prevent neonatal ophthalmia caused by N gonorrhea and C trachomatis?

Answer 14

1. Neonatal ocular prophylaxis with erythromycin, the only agent currently available in Canada for this purpose, may no longer be useful and, therefore, should not be routinely recommended.
2. Paediatricians and other physicians caring for newborns, along with midwives and other health care providers, should become familiar with local legal requirements concerning ocular prophylaxis.
3. Paediatricians and other physicians caring for newborns should advocate to rescind ocular prophylaxis regulations in jurisdictions in which this is still legally mandated.
4. Jurisdictions in which ocular prophylaxis is still mandated should assess their current rates of neonatal ophthalmia and consider other, more effective preventive strategies, as outlined below.

Question 15

What are the CPS recommendations regarding screening and treatment of pregnant women to prevent neonatal ophthalmia caused by N gonorrhea and C trachomatis?

Answer 15

1. All pregnant women should be screened for N gonorrhoeae and C trachomatis infections at the first prenatal visit.
2. Those who are infected should be treated during pregnancy, tested after treatment to ensure therapeutic success and tested again in the third trimester or, failing that, at time of delivery. Their partners should also be treated. Women who test negative but are at risk for acquiring infection later in pregnancy should be screened again in the third trimester. Rescreening for N gonorrhoeae, C trachomatis and other STIs should be considered in the third trimester for women who are not in a stable monogamous relationship.
3. Processes should be in place to ensure communication between physicians and others caring for a woman during pregnancy, and those who will care for her newborn. Information regarding maternal STI screening, treatment and risk factors is crucial to the well-being of the newborn, and must be available to all health care providers caring for the newborn at and following delivery.
4. Pregnant women who were not screened during pregnancy should be screened for N gonorrhoeae and C trachomatis at delivery, using the most rapid tests available

Question 16

What are the CPS recommendations regarding managing newborns exposed to N gonorrhoeae?

Answer 16

1. A system should be established to ensure that all infants born to mothers found to have untreated N gonorrhoeae infection at delivery are treated.
2. If the mother’s test results are not available at discharge, a plan must be in place to ensure that she can be contacted promptly if the results are positive. The mother must also be advised to watch her infant for eye discharge in the first week of life and told whom to contact immediately if this symptom develops, or if the child is unwell in any way. When there is doubt about maternal compliance with this recommendation and the mother is considered to be at risk for gonococcal infection, administering one dose of ceftriaxone should be considered for the infant before discharge.
3. Infants born to women with untreated N gonorrhoeae infection at the time of delivery, including those born by Caesarian section, should be tested and treated immediately without waiting for test results.
   a) Infants exposed to N gonorrhoeae who appear to be healthy at birth, both term and preterm, should have a conjunctival culture for N gonorrhoeae and receive a single dose of ceftriaxone (50 mg/kg to a maximum of 125 mg) intravenously or intramuscularly. The preferred diluent for intramuscular ceftriaxone is 1% lidocaine without epinephrine (0.45 mL/125 mg). This intervention is both safe and effective. Biliary stasis from ceftriaxone is not considered to be a risk with a single dose. (Ceftriaxone is contraindicated in newborns receiving intravenous calcium. A single dose of cefotaxime [100 mg/kg given intravenously or intramuscularly] is an acceptable alternative.)
   b) If the exposed infant is unwell in any way, blood and cerebrospinal fluid cultures should also be performed. Infants with established gonococcal disease require additional investigation and therapy in consultation with a specialist in paediatric infectious diseases

Question 17

What are the CPS recommendations for managing newborns exposed to C trachomatis?

Answer 17

1. Infants born either vaginally or by Caesarian section to mothers with an untreated chlamydia infection should be closely monitored for symptoms (eg, conjunctivitis, pneumonitis) and treated if infection occurs.Routine cultures should not be performed on asymptomatic infants.
2. Prophylaxis of exposed newborns is not recommended because of the association of macrolides with pyloric stenosis, but may be considered when infant follow-up cannot be guaranteed