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Preventing ophthalmia neonatorum





POSITION STATEMENT Preventing ophthalmia neonatorum
Dorothy L Moore, Noni E MacDonald; Canadian Paediatric Society, Infectious Diseases and Immunization Committee
Paediatr Child Health 2015;20(2):93-96
Posted: Mar 6 2015
well as the availability of products for prophylaxis, have all changed, raising concerns about the utility of the previously The use of silver nitrate as prophylaxis for neonatal oph­ thalmia was instituted in the late 1800s to prevent the devastating effects of neonatal ocular infection with Neis­ Neonatal ophthalmia, a relatively common illness, is defined seria gonorrhoeae. At that time – during the preantibiotic as conjunctivitis occurring within the first four weeks of life.
era – many countries made such prophylaxis mandatory Originally, this term only referred to cases caused by N gonor­ by law. Today, neonatal gonococcal ophthalmia is rare in rhoeae, but the term currently encompasses any conjunctivitis Canada, but ocular prophylaxis for this condition remains in this age group. N gonorrhoeae now accounts for <1% of re­ mandatory in some provinces/territories. Silver nitrate ported cases of neonatal ophthalmia in the United States, drops are no longer available and erythromycin, the only while that due to Chlamydia trachomatis ranges from 2% to ophthalmic antibiotic eye ointment currently available for 40%. Other bacteria such as Staphylococcus species, Strepto­ use in newborns, is of questionable efficacy. Ocular pro­ coccus species, Haemophilus species and other Gram- nega­ phylaxis is not effective in preventing chlamydial conjunc­ tive bacterial species account for 30% to 50% of cases.
tivitis. Applying medication to the eyes of newborns may Much less commonly, neonatal conjunctivitis is caused by vi­ result in mild eye irritation and has been perceived by ral infections (herpes simplex, adenovirus, enteroviruses). In­ some parents as interfering with mother-infant bonding. fectious conjunctivitis must be distinguished from eye dis­ Physicians caring for newborns should advocate for re­ charge secondary to blocked tear ducts and from conjunctivi­ scinding mandatory ocular prophylaxis laws. More effec­ tis due to exposure to chemical or other irritants.
tive means of preventing ophthalmia neonatorum include screening all pregnant women for gonorrhea and chlamy­ In most instances, neonatal ophthalmia is a mild illness. The dia infection, and treatment and follow-up of those found exception is ophthalmia due to infection with N gonorrhoeae.
to be infected. Mothers who were not screened should be Without preventive measures, gonococcal ophthalmia oc­ tested at delivery. Infants of mothers with untreated gono­ curs in 30% to 50% of infants exposed during delivery coccal infection at delivery should receive ceftriaxone. In­ and may progress quickly to corneal ulceration, perforation of fants exposed to chlamydia at delivery should be followed the globe and permanent visual impairment. Infants at in­ closely for signs of infection.
creased risk for gonococcal ophthalmia are those whose moth­ers are at risk for sexually transmitted infections (STIs).
Key Words: Chlamydia; Gonococcus; Neonatal oph­thalmia; Prophylaxis; Screening in pregnancy; STIs Historically, the purpose of prophylaxis for neonatal oph­thalmia was to prevent devastating neonatal eye infection due to N gonorrhoeae. Silver nitrate prophylaxis against N gonor­rhoeae ophthalmia neonatorum, first used by Dr Carl Credé in 1880, was a significant preventive medicine triumph at a time when there was no effective treatment available for gon­ The present statement replaces a statement on neonatal oph­ orrhea. Nevertheless, silver nitrate was not a perfect agent be­ thalmia published in 2002 by the Canadian Paediatric cause it caused transient chemical conjunctivitis in 50% to Society's Infectious Diseases and Immunization Committee.
90% of infants. Also, some parents were concerned that the This update is indicated because in Canada, the epidemiolo­ practice could interfere with mother-infant bonding. Silver gy and antibiotic susceptibility of Neisseria gonorrhoeae, as nitrate eye drops are no longer available in Canada. Tetracy­ INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE, CANADIAN PAEDIATRIC SOCIETY 1
cline and erythromycin ointments have been considered to be Public Health Agency of Canada recommends testing con­ acceptable alternatives for preventing gonococcal ophthalmia.
junctival and nasopharyngeal secretions of symptomatic in­ However, N gonorrhoeae strains isolated in Canada in fants and treating those who show positive r 2012 showed considerable resistance to these agents, with tetracycline at 30% and erythromycin at 23%. Whether A recent meta-analysis concluded that evidence from random­ this resistance can be overcome by the high local antibiotic ized and quasirandomized trials regarding the efficacy of pro­ levels achieved by topical application is unknown, and there phylactic agents used to prevent gonococcal and chlamydia are no recent studies of the efficacy of ophthalmia prophylax­ conjunctivitis was not of high quality. Moreover, all of the is with these agents.
agents reviewed had clinically significant failure rates.
In Canada, erythromycin has been the only antibiotic eye Rates of neonatal ophthalmia caused by N gonorrhoeae and ointment available for use in neonates since tetracycline oph­ C trachomatis declined significantly in North America thalmic ointment became unavailable. Povidone-iodine has through the 1980s due to the decreased prevalence of these been considered for proph but this agent may not be infections in the general population, and the institution of effectiv and has been associated with a 5% rate of routine prenatal screening and treatment of these STIs in chemical Gentamicin ointment was used for pregnancy In the United States in 2002, the rate of newborn ocular prophylaxis during a shortage of ery­ neonatal ophthalmia was 8.5 per 100,000 births. National thromycin ointment in the United States in 2009, but result­ surveillance of neonatal ophthalmia was discontinued in ed in reports of severe ocular reactions. Other oph­ Canada in 2000 because of low incidence. Current rates of thalmic antibiotic preparations have not been evaluated in infection can be estimated from reported cases of chlamydia newborns. Therefore, it is questionable whether universal oc­ and gonorrhea in infants <1 year of age, for whom the aver­ ular prophylaxis for neonatal gonococcal ophthalmia remains age national rate between 2000 and 2011 was six per 100,000 an effective option in Canada. Of note, universal ocular pro­ for chlamydia infection and 0.5 per 100,000 for gonorrhea.
phylaxis was abandoned decades ago in several high-income In Ontario, the combined rate of chlamydia and gonococcal countries including Denmark, Norway, Sweden and the Unit­ ophthalmia in 2004 was 4.5 per 1 There were no re­ ed Kingdom. One study from the United Kingdom showed ported cases of neonatal gonococcal ophthalmia in Alberta that this change did not increase the rate of blindness due to between 2005 and 2013, but rates of chlamydial ophthalmia gonococcal ophthalmia. However, the Canadian Medical ranged from 0 to 12.2 per 100,000 per year, with a reported Protective Association established that in 2013, neonatal ocu­ rate of 7.5 per 100,000 in 201areas of the world where lar prophylaxis was required by law in Alberta, British Colum­ prenatal screening and treatment are not available and preva­ bia, Ontario, Prince Edward Island and Quebec. In British lence of gonococcal infections is high, vision loss from neona­ Columbia, prophylaxis may be waived if a parent makes a tal gonococcal ophthalmia continues to occur and ocular pro­ written request. In New Brunswick, the law requiring prophy­ phylaxis with silver nitrate continues to be an important and laxis was repealed in 2009. No current legislation was found for the remaining provinces and territories.
If ocular prophylaxis must be given to comply with provin­ Infants born to women with untreated chlamydia infection at cial/territorial regulations, 0.5% erythromycin base can be delivery have a 50% risk of acquiring chlamydia, a 30% to used and may be effective in some cases, depending on the 50% risk of developing neonatal conjunctivitis and a 10% to antibiotic sensitivity of circulating strains. Povidone-iodine or 20% risk of developing chlamydia opical ocu­ gentamicin ointment should not be used because of high lar prophylaxis does not prevent transmission from mother to rates of adverse topical effects. To prevent potential cross- infant, does not reliably prevent neonatal conjunctivitis and contamination, single-use tubes of erythromycin are used. Be­ does not prevent pneumonia. Oral erythromycin pro­ fore administration, each eyelid is wiped gently with sterile phylaxis of infants born to untreated mothers has been used cotton to remove foreign matter and to permit adequate ever­ in the past but has not been recommended since the associa­ sion of the lower lid. A line of antibiotic ointment, sufficient­ tion between erythromycin and pyloric stenosis was recog­ ly long to cover the entire lower conjunctival area, is placed in nized. Routine prenatal screening for C trachomatis and each lower conjunctival sac, taking care to prevent injury to treatment of identified infections during pregnancy is the pre­ the eye or the eyelid from the tip of the tube. The closed eye­ ferred option for preventing neonatal conjunctivitis and other lids are massaged gently to help spread the ointment. After 1 infections in newborns caused by this organism. Close clini­ min, excess ointment is gently wiped from the eyelids and sur­ cal follow-up of exposed infants is r The rounding skin with sterile cotton.
2 PREVENTING OPHTHALMIA NEONATORUM
• Processes should be in place to ensure communication be­ To prevent neonatal ophthalmia caused by N gonorrhoeae tween physicians and others caring for a woman during and C trachomatis, the Canadian Paediatric Society recom­ pregnancy, and those who will care for her newborn. In­ mends the following: formation regarding maternal STI screening, treatment and risk factors is crucial to the well-being of the new­ Neonatal ocular prophylaxis:
born, and must be available to all health care providers caring for the newborn at and following delivery.
• Neonatal ocular prophylaxis with erythromycin, the only agent currently available in Canada for this purpose, may • Pregnant women who were not screened during pregnan­ no longer be useful and, therefore, should not be routine­ cy should be screened for N gonorrhoeae and C tra­ ly recommended.
chomatis at delivery, using the most rapid tests available.
• Paediatricians and other physicians caring for newborns, along with midwives and other health care providers, Managing newborns exposed to N gonorrhoeae:
should become familiar with local legal requirements con­cerning ocular prophylaxis.
• A system should be established to ensure that all infants born to mothers found to have untreated N gonorrhoeae • Paediatricians and other physicians caring for newborns infection at delivery are treated.
should advocate to rescind ocular prophylaxis regulations in jurisdictions in which this is still legally mandated.
• Jurisdictions in which ocular prophylaxis is still mandated should assess their current rates of neonatal ophthalmia and consider other, more effective preventive strategies, as outlined below.
Screening and treatment of pregnant women:
• All pregnant women should be screened for N gonor­ rhoeae and C trachomatis infections at the first prenatal visit.
• Those who are infected should be treated during pregnan­ cy, tested after treatment to ensure therapeutic success and tested again in the third trimester or, failing that, at time of delivery. Their partners should also be treated. Women who test negative but are at risk for acquiring in­fection later in pregnancy should be screened again in the third trimester Rescreening for N gonorrhoeae,C trachomatis and other STIs should be considered in the third trimester for women who are not in a stable monogamous relationship.
INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE, CANADIAN PAEDIATRIC SOCIETY 3
• If the mother's test results are not available at discharge, a plan must be in place to ensure that she can be contacted This statement has been reviewed by the Community Paedi­ promptly if the results are positive. The mother must also atrics and Fetus and Newborn Committees of the Canadian be advised to watch her infant for eye discharge in the Paediatric Society, as well as by the Public Health Agency of first week of life and told whom to contact immediately if Canada's Canadian STI Guidelines Expert Working Group this symptom develops, or if the child is unwell in any and representatives from the Society of Obstetricians and Gy­ way. When there is doubt about maternal compliance naecologists of Canada.
with this recommendation and the mother is considered to be at risk for gonococcal infection, administering one dose of ceftriaxone should be considered for the infant before discharge.
1. Canadian Paediatric Society, Infectious Diseases and Immu­ nization Committee. Recommendations for the prevention of • Infants born to women with untreated N gonorrhoeae in­ neonatal ophthalmia. Paediatr Child Health 2002;7(7):480-3.
fection at the time of delivery, including those born by 2. American Academy of Pediatrics. Prevention of neonatal oph­ Caesarian should be tested and treated imme­ thalmia. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious diately without waiting for test results.
Diseases, 29th ed. Elk Grove Village, IL. American Academy of – Infants exposed to N gonorrhoeae who appear to be healthy at birth, both term and preterm, should have 3. Laga M, Plummer FA, Nzanze H, et al. Epidemiology of oph­ a conjunctival culture for N gonorrhoeae and receive thalmia neonatorum in Kenya. Lancet 1986;2(8516):1145-9.
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cerebrospinal fluid cultures should also be performed. 8. Nishida H, Risenberg HM. Silver nitrate ophthalmic solution Infants with established gonococcal disease require and chemical conjunctivities. Pediatrics 1975;56(3):368-73.
additional investigation and therapy in consultation 9. Butterheld PM, Emdh RN, Svejda MJ. Does the early applica­ with a specialist in paediatric infectious diseases.
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cultures should not be performed on asymptomatic in­ 12. Isenberg SJ, Apt L, Wood M. A controlled trial of povidone-io­ dine as prophylaxis against ophthalmia neonatorum. N Engl J Med 1995;332(9):562-6.
• Prophylaxis of exposed newborns is not recommended be­ 13. Ali Z, Khadije D, Elahe A, Mohammad M, Fateme Z, Narges Z. cause of the association of macrolides with pyloric steno­ Prophylaxis of ophthalmia neonatorum comparison of beta­ sis, but may be considered when infant follow-up cannot dine, erythromycin and no prophylaxis. J Trop Pediatr 2007; be guaranteed.
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29. Public Health Agency of Canada. Notifiable Diseases On-Line. 15. David M, Rumelt S, Weintraub Z. Efficacy comparison between Gonococcal ophthalmia neonatorum. Number of Reported povidone iodine 2.5% and tretracycline 1% in prevention of Cases, Canada, 1990 to 1999. Accessed November 27, 2014.
ophthalmia neonatorum. Ophthalmology 2011;118(7):1454-8.
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Members: Natalie A Bridger MD; Jane C Finlay MD (past
23. Bell TA, Sandström KI, Gravett MG, et al. Comparison of oph­ member); Susanna Martin MD (Board Representative); Jane thalmic silver nitrate solution and erythromycin ointment for C McDonald MD; Heather Onyett MD; Joan L Robinson prevention of natally acquired Chlamydia trachomatis. Sex Transm Dis 1987;14(4):195-200.
MD (Chair); Marina I Salvadori MD (past member); Otto G 24. Chen JY. Prophylaxis of ophthalmia neonatorum: Comparison of silver nitrate, tetracycline, erythromycin and no prophylaxis. Liaisons: Upton D Allen MBBS, Canadian Pediatric AIDS
Pediatr Infect Dis J 1992;11(12):1026-30.
Research Group; Michael Brady MD, Committee on Infec- 25. Hammerschlag MR, Cummings C, Roblin PM, Williams TH, tious Diseases, American Academy of Pediatrics; Charles PS Delke I. Efficacy of neonatal ocular prophylaxis for the preven­ Hui MD, Committee to Advise on Tropical Medicine and tion of chlamydial and gonococcal conjunctivitis. N Engl J Med Travel (CATMAT), Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive 26. Black-Payne C, Bocchini JA Jr, Cedotal C. Failure of ery­ (IMPACT); Dorothy L Moore MD, National Advisory Com- thromycin ointment for postnatal ocular prophylaxis of chlamy­dial conjunctivitis. Pediatr Infect Dis J 1989;8(8):491-5.
mittee on Immunization (NACI); Nancy Scott-Thomas MD, 27. Rosenman MB, Mahon BE, Downs SM, Kleiman MB. Oral College of Family Physicians of Canada; John S Spika MD, erythromycin prophylaxis vs watchful waiting in caring for new­ Public Health Agency of Canada borns exposed to Chlamydia trachomatis. Arch Pediatr Adolesc sultant: Noni E MacDonald MD
28. Public Health Agency of Canada, Centre for Communicable Princi pal authors: Dorothy L Moore MD, Noni E MacDon-
Diseases and Infection Control. Canadian guidelines on sexual­ Also available at www.cps.ca/en
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