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Neonatal Bacterial Conjunctivitis in Korea in the 21St Century

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Neonatal Bacterial Conjunctivitis in Korea in the 21St Century CLINICAL SCIENCE Neonatal Bacterial Conjunctivitis in Korea in the 21st Century Kang Yeun Pak, MD,* Sung Il Kim, MD,†‡ and Jong Soo Lee, MD, PhD†‡ surface lubrication and bacterial clearance by tearing, abun- Purpose: To investigate the microbial cause and antibiotic dance mucosal immune cells in the conjunctiva, and antibac- susceptibility of neonatal bacterial conjunctivitis in Korean patients terial effect of tears.2 These mechanisms are immature in in the 21st century. neonates, and consequently, bacterial conjunctivitis is one of Methods: We retrospectively reviewed the medical records of the most common neonatal infections. patients diagnosed with neonatal bacterial conjunctivitis between Neisseria gonorrhoeae and Chlamydia trachomatis in January 2000 and December 2015. We recorded the organism, the maternal birth canal cause neonatal inclusion conjuncti- antibiotic susceptibility, and antibiotics used. vitis and were major causes of microbial neonatal conjunc- tivitis before the 21st century. But the incidence of neonatal Results: A total of 82 neonates were included in the study (53 conjunctivitis has decreased because of development of males and 29 females), with a mean age of 17.5 6 7.1 days. The antibiotics, more widespread use of prepartum examination, most commonly isolated organisms were Staphylococcus aureus (43 and increased use of cesarean section.3 cases, 52.4%), coagulase-negative staphylococci (11 cases, 13.4%), Methicillin-resistant Staphylococcus aureus (MRSA) is Staphylococcus epidermidis (11 cases, 13.4%), Serratia marcescens increasingly recognized as a significant pathogen. Becerra (4 cases, 4.9%), Pseudomonas aeruginosa (4 cases, 4.9%), and et al4 reported that 1 in 5 children in intensive care units had Enterobacter cloacae (3 cases, 3.7%). We found no cases of acquired an MRSA infection. A large-scale study of ocular Neisseria gonorrhoeae or Chlamydia trachomatis infection. Resis- MRSA5 has reported an increase in the incidence and tance to methicillin (83.7%), macrolide (81.4%), and aminoglyco- resistance of this pathogen. Conjunctivitis was reported as side (23.3%) was observed in patients with S. aureus infection. the predominant presentation, and it was very common in Conjunctivitis that did not improve with erythromycin or tobramycin neonates. However, reports on the incidence of MRSA in generally improved with the additional use of tosufloxacin. neonatal conjunctivitis in Korea are limited. The purpose of this study was to investigate the Conclusions: The prevalence of neonatal gonococcal or chlamyd- microbial causes and antibiotic sensitivity of neonatal bacte- ial conjunctivitis has decreased in the 21st century. However, rial conjunctivitis with review of the literature. methicillin-resistant S. aureus has been increasing, but these cases are responsive to tosufloxacin. Key Words: bacteria, culture, neonatal conjunctivitis MATERIALS AND METHODS (Cornea 2017;36:415–418) This study is a retrospective review of the medical records of patients who were diagnosed with neonatal bacterial conjunctivitis between January 2000 and December acterial conjunctivitis, an inflammation of the conjunctiva 2015 in Pusan National University Hospital. The institutional Bdue to abnormal proliferation of bacteria, requires accu- review board of Pusan National University Hospital approved rate diagnosis and treatment because it can cause severe the study protocol, and the protocol complied with the tenets complications, although the prognosis is good in most cases.1 of the Declaration of Helsinki. The outer eye has several defense mechanisms to maintain The inclusion criteria were as follows: the patient was homeostasis such as the blinking action of the eyelids, ocular less than 4 weeks old, a positive culture result was obtained from conjunctival discharge, and antibiotic sensitivity results were available for the culture. We recorded age, sex, place of Received for publication August 10, 2016; revision received October 26, birth, type of delivery, type of prophylactic antibiotics used, 2016; accepted November 13, 2016. Published online ahead of print organisms cultured, and the antibiotic susceptibility of the December 20, 2016. infectious organism. The patients were classified into 4 From the *Department of Ophthalmology, Haeundae Paik Hospital, Inje University, Busan, Korea; †Department of Ophthalmology, School of groups by age interval of a week and most common organism, Medicine, Pusan National University, Busan, Korea; and ‡Medical and incidence of MRSA was investigated in each group. Research Institute, Pusan National University Hospital, Busan, Korea. Bacterial culture was performed on the lower conjunctival sac The authors have no funding or conflicts of interest to disclose. using a smear of conjunctival discharge. The lower eyelid was Reprints: Jong Soo Lee, MD, PhD, Department of Ophthalmology, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan KS012, pulled to expose the lower conjunctival sac, and a sterile Korea (e-mail: [email protected]). cotton-tipped swab was used to collect the smear. The swab Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. was then put into a transport medium tube and sent to the Cornea Volume 36, Number 4, April 2017 www.corneajrnl.com | 415 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Pak et al Cornea Volume 36, Number 4, April 2017 TABLE 1. Organisms Cultured From Patients With Neonatal Bacterial Conjunctivitis Organism No. Eyes (%) S. aureus 43 (52.4) MRSA 36 (43.9) Non-MRSA 7 (8.5) Coagulase-negative Staphylococcus 11 (13.4) S. epidermidis 11 (13.4) S. marcescens 4 (4.9) P. aeruginosa 4 (4.9) Enterobacter 3 (3.7) K. pneunoniae 2 (2.4) C. striatum 1 (1.2) S. mitis 1 (1.2) A. baumannii 1 (1.2) FIGURE 1. Incidence of S. aureus and MRSA in neonatal E. faecalis 1 (1.2) conjunctivitis according to age groups. week, 55.6% (15/27) in age ,2 weeks, 44.1% (15/34) in microbiological laboratory. The specimen was inoculated age ,3 weeks, and 69.2% (9/13) in age .3 weeks. The onto blood, chocolate, and MacConkey agar media at 37°C incidence of MRSA was higher in age ,3 weeks (14/15, for 48 hours. The organisms were identified using the Vitek II 93.3%), but there was no significant difference between the system (bioMérieux, France). groups (P = 0.206, Fig. 1). Antibiotic susceptibility testing was performed by the Of the 43 cases of S. aureus infection, 26 of the patients broth microdilution method against clindamycin, erythromycin, were born in the Pusan National University hospital. Eryth- gentamicin, oxacillin, penicillin, bactrim, and vancomycin. We romycin was used in 23 neonates and tobramycin in 3 also reviewed all cases in which eye drops for ocular pro- neonates as a prophylactic treatment. One from 23 patients phylaxis were used in the infantile unit between January 2010 treated with erythromycin and 1 from 3 patients treated with and December 2015. Cases that required additional eye drops tobramycin were found to be resistant to treatment. All these were identified by a computerized search. patients improved after the use of tosufloxacin, a third- Statistical analysis was performed using SPSS 12.0 generation fluoroquinolone. (IBM Corporation, New York, NY). Differences were The rate of MRSA was found to be much higher in the assessed using the Fisher exact test and the x2 test. P , Pusan National University Hospital (26/26, 100%) than other 0.05 was considered statistically significant. hospitals (10/17, 58.8%, P , 0.001, Fisher exact test). Of 71 cases in which the type of delivery was known, 43 cases were delivered by cesarean section and 28 cases by RESULTS normal vaginal delivery. S. aureus was the most common A total of 82 neonates (53 males and 29 females) who infectious organism in both groups. The second most common met the eligibility criteria were included in the study. The mean infectious organism was coagulase-negative Staphylococcus in age was 17.5 6 7.1 days. There were 3 cases of coinfection. the cesarean section group and S. epidermidis in the normal ThemostcommonlyisolatedorganismswereS. aureus (n = vaginal delivery group (Table 2). There was no statistical 43, 52.4%), followed by coagulase-negative staphylococci (n = difference in MRSA according to the type of delivery. 11, 13.4%), Staphylococcus epidermidis (n = 11, 13.4%), Between January 2010 and December 2015, erythro- Serratia marcescens (n = 4, 4.9%), Pseudomonas aeruginosa mycin was used in 659 neonates and tobramycin was used in (n = 4, 4.9%), Enterobacter cloacae (n = 3, 3.7%). Klebsiella 728 neonates to provide ocular prophylaxis. A total of 90 pneumonia (2 cases, 2.4%), and one case each of Corynebac- cases (13.7%) from the erythromycin group and 35 cases terium striatum, Streptococcus mitis, Acinetobacter baumannii, (4.8%) from the tobramycin group required additional and Enterococcus faecalis. We found no cases of N. gonor- antibiotic treatment. The tobramycin group showed a signif- rhoeae or C. trachomatis infection (Table 1). icantly lower incidence of purulent eye (P , 0.001, x2 test). Most cases (n = 36, 83.7%) of S. aureus were associated with MRSA that were resistant to oxacillin. S. aureus showed a high rate of resistance to some of the most commonly used DISCUSSION active ingredients of eye drops, including penicillin (n = 39, Historically, neonatal gonococcal conjunctivitis has been 90.7%), clindamycin (n = 29, 67.4%), and erythromycin (n = one of the major causes of blindness in newborns, but the 35, 81.4%), as well as a low rate of resistance to gentamicin introduction of Crede prophylaxis using silver nitrate in 1881 led (n = 10, 23.3%). Only one case was resistant to bactrim and to significant reduction in the incidence of blindness.6–8 vancomycin, but it was sensitive to gentamicin. However, gonococcal conjunctivitis is still a disease that causes The most common organism was S. aureus in all age blindness in approximately 10,000 newborns per year world- groups. The incidence of S. aureus was 50% (4/8) in age ,1 wide, so it is clearly still a serious and important condition.9 In 416 | www.corneajrnl.com Copyright © 2016 Wolters Kluwer Health, Inc.
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