Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study.

OBJECTIVE: Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation. METHODS: This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics. RESULTS: Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis . Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases. CONCLUSIONS: Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Case series and literature review of chlamydial ophthalmia neonatorum in Botswana.

BACKGROUND: We describe 12 cases of chlamydial ophthalmia neonatorum and the current scientific evidence on its prevention and treatment. The data presented were obtained from the "Maduo" study, a prospective observational study of the relationship between curable sexually transmitted infections and adverse neonatal outcomes at four antenatal clinics in Gaborone, Botswana. METHODS: Infants of mothers with perinatal chlamydia infection were evaluated for chlamydial ophthalmia neonatorum based on clinical presentation of conjunctivitis or positive test via GeneXpert CT/NG assay. Data on 29 infants born to mothers with postnatal C. trachomatis infection were analysed. RESULTS: 12 infants were diagnosed with chlamydial ophthalmia neonatorum. Eight of those cases were confirmed with the GeneXpert CT/NG assay while four were identified as probable cases based on clinical history and presentation. Overall, nine infants presented with signs of conjunctivitis, while three who had a positive diagnostic test result had asymptomatic infection. All but one infant had received ocular 1% tetracycline prophylaxis at birth, and four infants had signs suggestive of chlamydial pneumonia at presentation. Two out of five symptomatic cases whose mothers reported completion of their treatment course with erythromycin had lingering symptoms. CONCLUSIONS: Our findings affirm that the current prophylaxis and treatment modalities for chlamydial ophthalmia neonatorum are inadequate. To the extent feasible in low- and middle-income countries, we recommend implementation of routine C. trachomatis screening and treatment in pregnant women.

Neonatal ocular prophylaxis in the United States: is it still necessary?

INTRODUCTION: Much has changed since Credé reported that silver nitrate decreases the incidence of ophthalmia neonatorum. Prenatal screening and treatment of pregnant women for Neisseria gonorrhoeae became standard in the 1950s and for Chlamydia trachomatis in 1993. Neonatal gonococcal and chlamydial conjunctivitis are consequently uncommon today. Currently, only 0.5% erythromycin ophthalmic ointment is available in the United States (U.S.) for neonatal ocular prophylaxis, which is ineffective against C. trachomatis. AREAS COVERED: This article addresses the altered epidemiology of ophthalmia neonatorum in the U.S. since prophylactic practices began, the lack of data supporting ophthalmic erythromycin for prevention of neonatal gonococcal and chlamydial conjunctivitis, and the impact of prenatal screening and treatment of pregnant women for N. gonorrhoeae and C. trachomatis on conjunctivitis incidence. The authors discuss why erythromycin ophthalmic ointment is likely ineffective against gonococcal ophthalmia, including the development of macrolide resistance. Physiologic limitations and pharmacokinetic properties are considered with respect to ophthalmic erythromycin for the prevention of gonococcal and chlamydial conjunctivitis. EXPERT OPINION: Administration of erythromycin ophthalmic ointment for the prevention of neonatal conjunctivitis is not literature-supported. Prenatal screening and treatment of pregnant women is the most effective way to prevent ophthalmia neonatorum. National mandates for prophylaxis should be withdrawn.

Ophthalmia neonatorum in a tertiary referral children's hospital: A retrospective study.

OBJECTIVES: The purpose of this study was to examine the aetiology, investigation and management of ophthalmia neonatorum (ON) presenting to a tertiary referral children's hospital over 5 years. METHODS: The eye swab data of all neonates presenting to Children's Health Ireland at Temple Street (Dublin, Ireland) between 1st January 2013 and 3rd September 2018 was analysed. The medical records of all patients with positive eye swab results were retrospectively reviewed. RESULTS: A total of 157 neonates had positive eye swab results. 54 cases were identified as ON. Chlamydia trachomatis (20.4%) was the most common organism identified, followed by Staphylococcus aureus (18.5%), Haemophilus influenzae (14.8%), Moraxella catarrhalis (7.4%), Streptococcus pneumoniae (5.6%), Escherischia coli (3.7%), Klebsiella pneumoniae (1.9%) and Pseudomonas aeruginosa (1.9%). A bacterial culture swab was tested in all cases (100%), a C. trachomatis/N. gonorrhoeae PCR swab in 70.4% and a viral PCR swab in 35.2%. On subanalysis of the cases that had C. trachomatis/N. gonorrhoeae PCR testing, C. trachomatis was responsible for 28.9% of cases. 50% of cases were hospitalised, intravenous antibiotics were administered in 46.3% and macrolide therapy was prescribed in 38.9%. CONCLUSIONS: C. trachomatis was the most common cause of ON in this study and may be responsible for an even higher proportion of cases due to incomplete testing. In keeping with studies in different populations, S. aureus, H. influenzae and S. pneumoniae were also common. As a result, an improved management algorithm for cases of ON has been introduced in this centre.

Culture Positive Cases of Ophthalmia Neonatorum in a Tertiary Care Centre of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Ophthalmia neonatorum although runs a benign course mostly, sometimes may progress to sight threatening complications. The study was conducted to find the prevalence of culture positive cases of opthalmia neonatorum. METHODS: It was a descriptive cross-sectional study conducted at a tertiary care center from January to December 2019. Ethical clearance was obtained from institutional review committee of Kathmandu Medical College. Convenience sampling was done. All data were entered into excel and, then for analysis, exported to Statistal Package for Social Sciences version 21. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: The prevalence of culture positive cases of opthalmia neonaturum is 10 (55.55%) (32.61-78.49 at 95% Confidence Interval). The causative organisms were coagulase negative Staphylococcus 4 (40%), Staphylococcus aureus 3 (30%), Klebsiella 2 (20%) and Pseudomonas 1 (10%). Culture sensitivity of the isolated organisms were different according to the patient even in case of the same organism. Vancomycin 7 ( 70%) was the most sensitive antibiotic followed by Ciprofloxacin 6 (60%), Amikacin 5 (50%) and Cloxacillin 5 (50%) while Azithromycin 1 (10%), Cefixime 1 (10%) and Cotrimoxazole 1 (10%) were the least sensitive. CONCLUSIONS: Staphylococcus species was the most common organism isolated from neonates with ophthalmia neonatorum and vancomycin was the most sensitive antibiotic.

Ophthalmia neonatorum as the presenting sign of SARS-CoV-2.

The most common ocular manifestation of SARS-CoV-2 in adults and children is acute conjunctivitis. We report the case of a 4-day-old infant who presented with acute-onset mucopurulent discharge of the left eye as well as subconjunctival hemorrhage and palpebral injection, without corneal findings. A diagnosis of ophthalmia neonatorum was established, for which ocular cultures and Gram staining were performed. No bacterial growth was noted, and polymerase chain reaction (PCR) testing for Chlamydia trachomatis, Neisseria gonorrhea, and herpes simplex were negative. Nasopharyngeal and conjunctival SARS-CoV-2 PCR were positive. Given the identification of SARS-CoV-2 illness, lack of other underlying bacterial or viral etiology on testing, and the well-documented ability for SARS-CoV-2 to cause conjunctivitis, the clinical picture was supportive of ophthalmia neonatorum secondary to SARS-CoV-2. The infant was treated with ceftriaxone and azithromycin prior to culture results. During admission, no systemic findings of Covid-19 illness were observed.

Using Historical Data to Support Approval of Drug Products for Ophthalmia Neonatorum: Innovative Approach Toward Evidence-Based Medicine.

Importance: Off-label treatment was common for ophthalmia neonatorum because only erythromycin ointment had been approved by the US Food and Drug Administration (FDA) for this indication. Ophthalmia neonatorum was previously considered a different indication from bacterial conjunctivitis in older children and adults because of uncertain similarities in the cause of disease and the treatment course between the 2 populations. Prospective therapeutic clinical studies were required to demonstrate the effectiveness of treatment for ophthalmia neonatorum. Objective: To review the therapeutic clinical trials for patients with bacterial conjunctivitis to evaluate the similarity in the cause of disease and the treatment response between neonates and older children and adults. Design, Setting, and Participants: In this comparative effectiveness research review of pooled data from the most recent 30 bacterial conjunctivitis trials (N = 2018) submitted to the FDA to support the approval of topical ophthalmic solutions for older children and adults, 95% CIs were constructed from clinical cure rates. Cure rates in 3 neonatal randomized clinical trials (N = 392) of patients treated with ophthalmic anti-infective solutions of ciprofloxacin, gatifloxacin, and moxifloxacin were constructed and compared. The baseline ocular swab cultures were analyzed. Main Outcomes and Measures: Cure rates of neonatal trials were compared with the 95% CIs among older children and adults. The bacterial organisms isolated from these 2 populations were compared. Results: The 3 neonatal trials enrolled a total of 392 patients, and the 30 trials of older children and adults enrolled a total of 2018 patients. Neonatal clinical cure rates for moxifloxacin (day 4, 48%), ciprofloxacin (day 4, 49%; day 5, 61%), and gatifloxacin (day 7, 79%) were within the 95% CI for products approved to treat older children and adults with bacterial conjunctivitis. Bacterial organisms were consistent between these 2 populations. Conclusions and Relevance: Comparison of the pooled analysis of these historical trial data suggests similarity in the cause of disease and the treatment response between neonates and older children and adults with bacterial conjunctivitis. Therefore, it was appropriate to extrapolate the effectiveness from older children and adults to neonates to support the approval of therapies for ophthalmia neonatorum. Based on this analysis, ophthalmic solutions of ciprofloxacin, gatifloxacin, and moxifloxacin are now approved for all age groups. This analysis presents an approach of using pooled data from previously underpowered individual trials to establish the similarities in the cause of disease and in treatment response between children and adults, which are the fundamental elements used to evaluate whether extrapolation of effectiveness can be used to support drug approval.

Neonatal Conjunctivitis Caused by Neisseria cinerea: A Case of Mistaken Identity.

We report a case of a 3-day-old boy with Neisseria cinerea conjunctivitis, originally misidentified as Neisseria gonorrhoeae conjunctivitis. Neonates are at increased risk for disseminated gonococcal infection, and physicians should be cognizant of N cinerea and its potential to be mistaken for N gonorrhoeae.

Gonococcal Conjunctivitis in Adults: Case Report and Retrospective Review of Cases in Alberta, Canada, 2000-2016.

BACKGROUND: A case of gonococcal conjunctivitis (GC) prompted us to review the reported cases and treatment regimens of GC in Alberta, Canada. METHODS: Gonococcal cases reported from 2000 to 2016 were extracted from the provincial sexually transmitted infection reporting database. The diagnosis of GC was based on a positive culture and/or nucleic acid amplification test from the eye. RESULTS: A total of 45 cases of GC were reported in adults. Three quarters (75.6%; n = 34) of the cases were diagnosed using culture, 57.8% (n = 26) of cases were among men, and 55.5% (n = 25) were diagnosed since 2014. Very few (13.3%; n = 6) of the cases were treated according to current Canadian Guidelines on Sexually Transmitted Infections, using 2 g of ceftriaxone in combination with azithromycin or doxycycline. Results of test of cures were available for 15.6% (n = 7) of the cases and occurred within 10 to 79 days (median = 26 days) after treatment; all were negative. CONCLUSIONS: Gonococcal conjunctivitis was relatively uncommon in our region, but given its potential for severe manifestations and sequelae coupled with the rising rates of gonorrhea; it remains important to consider this diagnosis in sexually active individuals presenting with purulent conjunctivitis. Additional studies are needed to inform treatment recommendations and to evaluate outcomes of infection.

Diagnosis of a neonatal ophthalmic discharge, Ophthalmia neonatorum, in the molecular age: investigation for a correct therapy.

An early double case of acute Ophthalmia neonatorum in 3-day-old twins is reported. Culture of eye swabs showed a wide bacterial polymorphism, in which common bacteria, such as Klebsiella pneumoniae, Streptococcus pneumoniae, Corynebacterium ulcerans and other Enterobacteriaceae, coexisted with atypical Mycoplasmataceae and Chlamydiaceae from resident cervical-vaginal maternal microbiota. The neonates were in an apparently healthy state, but showed red eyes with abundant greenish-yellow secretion, mild chemosis and lid edema. The maternal cervical-vaginal ecosystem resulted differently positive to the same common cultivable, atypical bacteria culturally and molecularly determined. This suggested a direct maternal-foetal transmission or a further foetal contamination before birth. An extended culture analysis for common bacteria to atypical ones was decisive to describe the involvement of Mycoplasmas (M. hominis and U. urealyticum) within the scenario of the Ophthalmia neonatorum in a Caucasian couple. The introduction of a routine PCR molecular analysis for Chlamydiaceae and N. gonorrhoeae allowed to establish which of these were present at birth, and contributed to determine the correct laboratory diagnosis and to define an adequate therapeutic protocol obtaining a complete resolution after one year for culture and atypical bacteria controls. This study suggests to improve the quality of laboratory diagnosis as unavoidable support to a correct clinical diagnosis and therapy, in a standardized modality both for swabbing and scraping, to check the new-born microbial programming starting in uterus, overtaking the cultural age to the molecular age, and to revise the WHO guidelines of SAFE Strategy for trachoma eye disease, transforming it into SAFES Strategy where the S letter is the acronym of Sexual ecosystem and behavioural valuation/education.

[Gonococcal ophthalmia neonatorum: Clinical illustration, prevention, and future prospects]. / Conjonctivite néonatale à Neisseria Gonorrhoeae : illustration clinique, prophylaxie et perspectives d'avenir.

A 6-day-old infant presented with a bilateral suppurative ocular discharge with a conjunctival erythema. Polymerase chain reaction was performed on the pus and showed the presence of Neisseria gonorrhoeae DNA. Therapy with intravenous cefotaxime was initiated and completed with local application of tobramycin. This infection was associated with a small unilateral corneal lesion, with rapid resolution. This case provides the opportunity to focus on newborn suppurative conjunctivitis and its treatment. The different prophylaxes available (silver nitrate, povidone-iodine, local antibiotics, etc.) and their respective advantages and disadvantages are reviewed. There is no clear consensus on the most effective solution. Additionally, universal prophylaxis is challenged in several countries, where it is no longer recommended.

Ophthalmia neonatorum treatment and prophylaxis: IPOSC global study.

INTRODUCTION: Characteristics of ophthalmia neonatorum (ON) amongst paediatric ophthalmologists remain unclear. The purpose of this current study is to examine the incidence, diagnosis, treatment, and prophylaxis of ON cases presenting to members of the American Association of Paediatric Ophthalmology and Strabismus (AAPOS). METHODS: An email containing a web link to a survey was sent to all members of AAPOS. The questionnaire examined the incidence of ON, etiology, diagnostic methods, treatment, and prophylaxis of the disease in different countries around the world. RESULTS: Two hundred and ninety-one ophthalmologists answered the questionnaire. Most were from North America (52.94 %). One hundred and seventy-six (60.69 %) ophthalmologists encountered 0-5 cases of ON per year. The most common pathogens causing ON was Chlamydia trachomatis (35.37 %). Two hundred and forty-two (85.21 %) treat empirically when encountering ON during the first 10 days of life and 205 (75.09 %) after the first 10 days of life. In both cases, erythromycin was the most common first line of treatment. Two hundred and twenty-two (78.72 %) ophthalmologists replied that prophylactic treatment is required in their country. The most common agent for prophylaxis was erythromycin ointment (71.50 %). CONCLUSIONS: We found that the incidence of ON per year per practitioner is 0-5 cases, the most common etiology is C. trachomatis, and most infants receive prophylaxis and treatment.

Klebsiella pneumonia: An unusual cause of ophthalmia neonatorum in a healthy newborn.

Ophthalmia neonatorum is one of the most common infections during the neonatal period. Chlamydia trachomatis and Neisseria gonorrhoea must be ruled out, given their high virulence and systemic complications. We describe a case of ophthalmia neonatroum from Klebsiella pneumonia. Gram-negative organisms have been reported in hospital-acquired conjunctivitis (HAC), but we are unaware of any published reports of K. pneumonia conjunctivitis in an otherwise healthy full-term infant born in the United States who has received prophylaxis. It is important to promptly identify and treat Klebsiella conjunctivitis because it can lead to severe complications.

Prevalence of gonococcal conjunctivitis in adults and neonates.

PURPOSE: To report the prevalence of gonococcal conjunctivitis (GC) presenting to a tertiary referral maternity hospital (NMH) and a tertiary referral ophthalmic hospital (RVEEH) from 2011 to 2013 and describe the demographics, clinical presentation, and antibiotic susceptibility of Neisseria gonorrhoeae ocular infections. METHODS: Demographic, clinical, and microbiological data were collected from patients with laboratory confirmed GC. RESULTS: There were 27 556 live births at NMH during the study period, and no case of neonatal GC was identified. Fourteen cases of GC were identified at RVEEH in this period, representing a prevalence of 0.19 cases per 1000 eye emergency attendees. Antibiotic susceptibility data were available on nine cases, of which, all were ceftriaxone- and ciprofloxacin sensitive. 64.3% of patients were male, with a mean age of 18 years. The mean duration of symptoms was 3 days. All patients presented with unilateral conjunctival injection and purulent discharge. Eight cases had visual impairment at presentation and their mean visual acuity was 6/15. Corneal involvement was present in 25% of patients. Uveitis was not detected. On receipt of positive culture and/or PCR results, treatment was altered in two thirds of patients. All patients were referred for full STI screening and all patients showed a full clinical recovery 1 week posttreatment. CONCLUSION: We observed that GC presented in young adults with a male predominance and was rare in neonates. In cases of unilateral purulent conjunctivitis, there should be a high clinical suspicion of GC, early swab for PCR and culture, and knowledge of current CDC-recommended antibiotic guidelines.

Prevalence of Chlamydia trachomatis among asymptomatic women.

BACKGROUND: Chlamydia trachomatis is a ubiquitous pathogen worldwide and causes ocular. urogenital, and respiratory infections in humans. C. trachomatis infection of lower genital tract is one of the most prevalent sexually transmitted diseases (STDs) in different parts of the world. Their treatment, follow-up, and hopefulness for future is very important. Objectives of this study were to see the prevalence of Chlamydia trachomatis infection among women of child bearing age and to determine the incidence of Chlamydia infection in neonates of women infected with Chlamydia. METHODS: This observational study was carried out in Department of Obstetrics & Gynaecology, CMH Abbottabad, and Department of Ophthalmology, Women Medical College Abbottabad from January 2012 to June 2012. Urine samples were collected from 200 women aged 20-39 years attending Obs/Gyn Department of CMH Abbottabad. After delivery, babies who were born to mothers with infection of their genital tracts were examined with a 2.5 x binocular loupe within a week of birth to rule out eye infection (Chlamydia Ophthalmic neonatorum). RESULTS: The overall prevalence of Chlamydia trachomatis was 4% in 200 eligible patients. The overall incidence of Chlamydia trachomatis in neonates was 1.66%. CONCLUSION: A significant proportion of women resident of Abbottabad District expressed evidence of exposure to Chlamydia trachomatis and significant number of neonate eyes were infected with the pathogen.