A 13-day-old boy is brought to the office by his parents for a well-newborn visit. The patient was born at 38 weeks gestation via normal spontaneous vaginal delivery to a 27-year-old woman, gravida 1 para 1. He had an uncomplicated newborn nursery course with routine newborn care and was discharged with his mother at age 2 days. The patient nurses for 15-20 minutes on each breast every 2 hours. He has approximately 7 wet diapers and 3 stools per day. Weight, length, and head circumference are at the 75th percentile. Vital signs are normal. On examination, the anterior fontanelle is open, soft, and flat. Pupils are equal, round, and reactive to light. Both eyes have mild eyelid swelling, conjunctival injection, and a scant amount of watery, slightly mucopurulent discharge. The parents say that this discharge began 2 days ago. The rest of the examination is normal. A sample of the eye discharge is sent for analysis. Which of the following is the most appropriate treatment for this patient's condition?
Neonatal conjunctivitis | |||
Type | Onset age | Findings | Treatment |
Chemical | <24 hr |
| Eye lubricant |
Gonococcal | 2-5 days |
| Single IM dose of 3rd- generation cephalosporin |
Chlamydial | 5-14 days |
| Oral erythromycin |
IM = intramuscular. | |||
This infant has bilateral conjunctival injection, eyelid swelling, and mucopurulent discharge, findings consistent with infectious conjunctivitis. In this case, symptom development in the second week of life is concerning for infection with Chlamydia trachomatis, which is acquired in neonates through contact with infected genital secretions during delivery. Although infection is often prevented by screening pregnant women (age <25 or with risk factors) and then treating prenatal infection, most infants with chlamydial conjunctivitis are born to mothers who were not screened or were infected after screening but before delivery.
Chlamydial conjunctivitis usually presents at age 5-14 days with mild eyelid swelling, watery or mucopurulent discharge, and chemosis (conjunctival edema). C trachomatis cannot be seen on Gram stain and does not grow in routine culture; PCR testing is needed to confirm the diagnosis.
Management of chlamydial conjunctivitis is oral erythromycin; patients should be monitored for pyloric stenosis, a potential adverse effect of oral macrolides in infants. Systemic treatment is required for chlamydial conjunctivitis because topical erythromycin alone has high failure rates (Choice D). Untreated infection may lead to corneal scarring and blindness. Notably, topical erythromycin ointment is routinely administered to all neonates at birth as prophylaxis against gonococcal conjunctivitis but does not prevent chlamydial disease.
(Choice A) A single intramuscular dose of a third-generation cephalosporin (eg, cefotaxime) is the treatment for gonococcal conjunctivitis. Gonococcal conjunctivitis is more severe than chlamydial conjunctivitis and generally presents in the first week of life with significant purulent eye discharge.
(Choice B) Massaging the nasolacrimal ducts is appropriate treatment for infants with duct obstruction (dacryostenosis), which typically presents with unilateral tearing and minimal conjunctival injection.
(Choice E) Silver nitrate is used in some countries for routine neonatal ophthalmic prophylaxis against Neisseria gonorrhoeae. It is banned in the United States because it can cause chemical conjunctivitis in the first 24 hours of life. It does not prevent or treat chlamydial conjunctivitis.
Educational objective:
Chlamydial conjunctivitis typically presents at age 5-14 days with mild eyelid swelling, chemosis, and watery or mucopurulent discharge. Management is oral erythromycin; topical treatments are not effective.