NEONATAL : From the time of Crede' when gono- A PROFILE coccal ophthalmia was common, to the present day, neonatal conjunctivitis remains one of the commonest infections encoun- tered in the newborns. Although the silver M. Verma nitrate prophylaxis advised by Crede'(l) J. Chhatwal more than a hundred years ago has gone a P.V. Varughese long way in reducing the gonococcal infec- tion of neonatal eyes, but other organisms continue to cause morbidity. The range of ABSTRACT offending agents is diverse, from bacteria to Neonatal conjunctivitis is one of the com- viruses and chlamydiae. Silver nitrate itself monest infections encountered in the newborn. A has also been implicated for causing chemi- prospective study was conducted on all babies cal conjunctivitis as well as other prob- born over a period of one year. No prophylactic lems(2). As a result many places have dis- ocular medication was instilled routinely in continued the silver nitrate prophylaxis or newborns. Babies developing purulent eye dis- charge were diagnosed to have conjunctivitis. are using other agents(3). In our hospital, no Eye Swab from the neonates and maternal vagi- prophylactic agent has been used for many nal/cervical swabs were sent for culture. years. Conjunctivitis being a common infec- Chloromycetin eye drops were used for treat- tion, the present study was planned to see ment and in case of no response, changed as per the incidence, causative agents and treat- sensitivity report or to gentamicin eye drops. ment response. As the facilities for chlamy- Oral erthromycin was given for or dial cultures or antibody estimation do not when there was no response to topical therapy. exist, this organism was not studied. The incidence of conjunctivitis was 7.2%. Two seasonal peaks, namely, February and then Material and Methods May and June, were noted. In 91.6% of the ba- bies, conjunctivitis developed within the first All babies born in the Obstetrics Depart- week. A prolonged rupture of membranes was ment over one year period were studied associated with a significantly higher incidence prospectively. The duration of ruptured of conjunctivitis (p <0.01). The most common membranes, unsterile pelvic examinations organism grown from conjunctival swab was done by Dais and (lie route of delivery were Staph aureus (35.2%) followed by Enterococcus also noted. (4.3%), Klebsiella (3.5%) and E. coli (2.8%). From vaginal/cervical swabs, E. coli was the As a routine hospital practice, eyes were most common organism isolated. No concur- wiped clean with sterile swabs and no pro- rence of organisms was noted between eye swabs phylactic medication was instilled in the and vaginal/cervical swabs. A uniformly good eyes. The babies who developed purulent response to chloromycetin eye drops was noted with only 3.5% requiring a change of therapy. From the Department of , Christian It is concluded that neonatal conjunctivitis Medical College, Ludhiana. is commonly acquired postnatally and responds Reprint requests: Dr. Manorama Verma, Profes- well to topical chloromycetin therapy. Oral sor and Head of Pediatrics, Christian Medi- may' be used in resistant cases cal College, Ludhiana 141 008. which will cover the chlamydial infection also. Received for publication: December! 3, 1993; Key words: Conjunctivitis, Neonate. Accepted: May 9th 1994 VERMA ET AL. NEONATAL CONJUNCTIVITIS eye discharge were diagnosed to have The onset of conjunctivitis was within the conjunctivitis. In all these babies, eye swabs first week in 91.6% of the babies and only were sent for culture before starting on any 8.4% developed eye discharge after 7 days treatment. Whenever possible, maternal (Table I). Rupture of membranes of more vaginal/cervical swabs were also sent. than 12 hours was found to increase the Babies were started on chloromycetin eye incidence of conjunctivitis significantly (p drops which were continued for 1-2 weeks. <0.01). Unsterile pelvic examinations did not In case of no response, the treatment was increase the likelihood of developing changed as per sensitivity report or to conjunctivitis. The incidence of . gentamicin eye drops. Oral erythromycin conjunctivitis was almost the same among was given when dacryocystitis was sus- babies delivered vaginally or by Cesarean pected or when there was no response to section (Table II). topical therapy. Statistical analysis was done using Chi square test. TABLE I -Age of Onset Results Of 1972 live births, 142 babies devel- Age No. % oped conjunctivitis, incidence being 7.2%. (days) The incidence was significantly (p <0.01) higher (8.7%) among male neonates as <1 4 2.8 compared to females (5.3%). 1-3 65 45.8 Two peaks of conjunctivitis, the first in 4-7 61 43.0 late winter, i.e., February and the second in >7 12 8.4 height of summer during the months of May and June were observed. Total 142 100.0

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Of 142 eye swabs cultured, 61 (43%) infection during the neonatal period(4,5). showed no growth and 5 (3.5%) were lost. The neonate's is more prone to The most common organism grown was infection as it has lower levels of lysozyme Staph. aureus (35.2%), followed by Entero-- and IgA in the tears and also the flow of coccus (4.3%), Klebsiella (3.5%), E. coli tears and the tear film are not developed (2.8%) and Pseudomonas (3.7%), (Table yet(6). The incidence of conjunctivitis III). Vaginal/cervical swabs could be sent in among newborns in the present study was 113 mothers (79.5%). No growth was seen 7.2% which is comparable to 8.4% reported in 60.3% and the commonest organism by Prentice et al. (7). Rao et al. observed grown was E. coli (17.7%) {Table IV). The that 57.2% of the studied by them organisms grown from the eye swab were had developed conjunctivitis by 48-72 h of matched with the ones isolated from mater- age(8). A much lower incidence of 0.87% nal vaginal/cervical swab and no concur- has been reported by Armstrong et al.(9). rence was noted. Marked seasonal variation was noted in the present study with two peaks of occurence A good response to chloromycetin eye first in February and second in summer. drops was seen in 96.5% of the babies and Armstrong et al. found that attack rates for only 3.5% required a change to gentamicin all types of conjunctivitis were more during eye drops. Two cases (1.4%) developed the third quarter of the year, i.e., July to dacryocystitis which responded well to oral October while staphylococcal conjunctivitis erythromycin and massaging of lacrimal was seen more often from April to sac. Parenteral antibiotics were given to October(9). 11.9% of babies for other reasons. The incubation period of conjunctivitis Discussion may be of help in knowing the causative Conjunctivitis or purulent discharge agent to a certain extent. While chemical from one or both eyes is the commonest conjunctivitis due to silver nitrate applica- tion occurs within 48 h of birth, chlamydial TABLE III- Organisms Cultured from Neo-

VERMA ET AL. NEONATAL CONJUNCTIVITIS more. Gonococcal infection has an early Some studies have reported a high degree of onset, i.e., within 1-4 days after birth. The correlation between the organisms grown onset with infection due to other orga- from maternal cervix and neonatal conjunc- nisms has been reported to be variable(l0). tivae soon after birth(8,14). As in the cur- A majority of the babies in the current study rent study, Staphylococci have been found had developed conjunctivitis within the 1st to be a common infecting agent by others week. Armstrong et al. in a chart review also(8,9,15). An increase in incidence of found the mean incubation period for gono- staphylococcal conjunctivitis has been an- coccal infection as 6.5 days while a signifi- ticipated by Armstrong et al. as the use of cantly longer period of 8.1 days was noted hexachlorophene is decreasing(9). for chlamydial infections(9). Rowe et al. In the present study, 42.9% of the con- also noted that more of chlamydial culture junctival cultures did not reveal any growth positive babies reported eye discharge after which may be explained by other organisms 6 days as compared to non-chlamydial in- like anaerobes or viruses. Similarly, fections(ll). In contrast, Sandstroms et al. Armstrong observed that 44.4% of the did not find any correlation of age of onset conjunctivitis was of uncertain etiology with the cause(12). while Prentice et al. could not isolate any The possibility that neonatal conjuncti- microorganism in 53.5% of cases(9,7). vitis is often contracted while passing through infected maternal passages has been We found a uniformly good response to well exemplified by studies on gonococcal chloromycetin eye drops and according to and chlamydial infections(9). The pro- sensitivity reports also 73.7% of the organ- longed rupture of membrane also increases isms were covered by this. Prentice et al. the likelihood of acquiring infection. In this observed an excellent response to study, the prolonged rupture of membranes (7). Pierce et al. have reported, increased the occurence of conjunctivitis after antibiotic sensitivity tests, that significantly. No difference was noted chloromycetin was effective against all among babies born vaginally or by Cesarean bacterial cases but not inclusion section. Unsterile pelvic examinations in conjunctivitis(13). For mild to moderate the mother also did not influence the devel- conjunctivitis, Sandstroms has recom- opment of conjunctivitis. Similarly, no cor- mended only lid hygiene. relation between conjunctivitis and various To summarize, neonatal conjunctivitis factors like prolonged labor, mechanical in- nowadays is more likely to be acquired tervention, vaginal examination has been postnatally. It occurs during the first week noted by others(7,8,13). Further, evidence and responds well to local chloromycetin that source of infection may be other than application which covers the common caus- maternal passages was found on correlating ative bacteria. In resistant cases, oral eryth- the cultures from conjunctiva and maternal romycin could be useful as it would also vagina. No concurrent growth of organisms help in treating ocular as well as systemic was noted. In addition, the most common chlamydial infection(15). organism in the present study was Staph. REFERENCES aureus which is known to be acquired after birth. In contrast, E. coli was more com- 1. Forbes GB, Forbes GM. Silver nitrate monly isolated from maternal cultures. and the eyes of the newborn-Crede's

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contribution to preventive medicine. Am J 9. Armstrong JH, Zacharias F, Rein HF. DisChiildl971, 121: 1-4. Opthalmia Neonatorum—A chart review. Pediatrics 1967, 57: 884-892. 2. Jarvis VN, Levin R, Asbell PA. Opthalmia neonatorum: Study of a decade 10. Overall JC. The fetus and neonatal . of experience at the Mount Sinai Hospital. In: Nelson's Textbook of Pediatrics, 13th Br J Opthalmol 1981, 71: 295-300. edn. Eds. Behrman RE, Vaughan VC. Philadelphia, WB Saunders Company. 3. Chandler JW. Controversies in ocular pro- 1987, p 429. phylaxis in newborns. Arch Ophthalmol 1989, 107: 814-815. 11. Rowe DS, Aicardi EZ, Dawsen CR, Schachter J. Purulent ocular discharge in 4. Saxena H, Srivastava JR, Goswami P. neonates. Significance of Chlamydia Bacterial infections of the newborn. trachomatis. Pediatrics 1979, 63: 628-632. Pediatr Clin India 1971, 6: 69-76. 12. Sandstrom KI, Bell TA, Chandler JW, el 5. Nellian AR, Choudhury P, Srinivasan S, al. Microbial causes of neonatal Nalini P, Puri RK. A prospective study of conjunctivitis. J Pediatr 1984, 105: 706- bacterial infections in the newborn. Indian 711. J Pediatr 1981, 48: 427-431. 13. Pierce JM, Ward ME, Seal DV. 6. Etches PC, Leachy F, Harris D, Baird JD. Opthalmia Neonatorum in the 1980's: Lysozyme in the tears of newborn babies. Incidence, etiology and treatment. Br J Arch Dis Child 1979, 54: 218-221. Ophthalmol 1982,66: 728-731. 7. Prentice MJ, Hutchinson GR, Taylor- 14. Singh PP, Gupta AP, Gupta A, Kumar C, Robinson D. A microbiological study of Mathur MC. Aerobic bacterial flora of neonatal conjunctivae and conjunctivitis. maternal cervix in relation to neonatal Br J Ophthalmol 1977, 61: 601-607. conjunctiva and gastric fluid. Indian 8. Rao K, Ramji S, Thirupuram S, Prakash Pediatr 1982, 19; 521-524. K. Clinical and bacteriological study of 15. Sandstrom I. Treatment of neonatal normal and inflamed neonatal conjuncti- conjunctivitis. Arch Ophthalmol 1987, vae. Indian Pediatr 1992, 29: 161-165. 105: 925-928.

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