A 3-day-old girl is brought to the emergency department due to profuse eye discharge. The infant's right eye began to have clear drainage and redness yesterday evening. The parents wiped the drainage away with a moist cloth. This morning, both eyes were involved and the discharge was heavy and purulent. The patient is breastfeeding well and voiding and stooling normally. She was born at term via vaginal delivery to a 24-year-old primigravida. The parents elected for an all-natural birth process and declined routine prenatal laboratory testing. The mother opted for unmedicated labor and delivery at a birthing center, and the infant received no medications postpartum. The mother and infant were discharged approximately 4 hours after delivery. Temperature is 36.9 C (98.4 F). On physical examination, bilateral eyelid swelling is seen. When the eyelids are opened, thick, purulent discharge is expressed. The remainder of the examination is unremarkable. Which of the following peripartum interventions would most likely have prevented this patient's condition?
Neonatal gonococcal conjunctivitis | |
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This neonate's profuse, purulent eye drainage and eyelid swelling at age 3 days are consistent with conjunctivitis secondary to Neisseria gonorrhoeae. Infants acquire gonococcal conjunctivitis through contact with infected maternal genital secretions. Gonococcal conjunctivitis has an earlier and more severe presentation compared with chlamydial conjunctivitis. Infection usually begins at age 2-5 days with severe eyelid swelling, mucopurulent discharge, and chemosis (conjunctival injection). Infected infants should receive a single intramuscular dose of a third-generation cephalosporin (eg, cefotaxime) for treatment. Without prompt treatment, gonococcal conjunctivitis leads to corneal ulcerating, scarring, and blindness.
Gonococcal conjunctivitis in neonates can be prevented by screening pregnant women and treating their infections. However, most infants with gonococcal conjunctivitis are born to mothers who did not receive screening or had negative screening early in pregnancy and were subsequently infected. Therefore, all infants should receive topical erythromycin prophylaxis within an hour of birth; this treatment is highly effective in the prevention of gonococcal disease.
(Choice A) Intramuscular penicillin is the treatment of choice for syphilis. Syphilis does not present with conjunctivitis in the neonatal period.
(Choice B) Intrapartum ampicillin is used for prophylaxis for mothers with a positive rectovaginal culture for group B Streptococcus but does not prevent the transmission of gonococcus to the infant.
(Choices C and D) Macrolide therapy (eg, oral azithromycin or erythromycin) is indicated for the treatment of chlamydial infection. Mothers who screen positive for Chlamydia trachomatis can be treated with oral macrolides during pregnancy; infants who acquire chlamydial disease (eg, conjunctivitis, pneumonia) also require oral therapy.
Educational objective:
Gonococcal conjunctivitis, which presents with copious mucopurulent drainage, chemosis, and eyelid swelling at age 2-5 days, can be prevented by the administration of erythromycin ointment shortly after delivery.