Conjunctivitis resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

Synonyms and keywords:

Conjunctivitis resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Conjunctivitis is a commonly encountered disorder in children and adults in both primary care and specialty eye care settings. The predominant causes of infectious conjunctivitis are viral and bacterial pathogens. Infectious conjunctivitis typically presents as a red eye with purulent or watery discharge and is usually self-limiting, but in rare cases can lead to complications such as keratitis and blindness. Conjunctivitis can occur in a newborn during the first month of life which is known as neonatal conjunctivitis or ophthalmia neonatorum with clinical signs of erythema and oedema of the eyelids and the palpebral conjunctivae, purulent eye discharge. The major causes of ophthalmia neonatorum are chemical inflammation, bacterial infection and viral infection.

Causes

Neonatal conjunctivitis

Life Threatening Causes

Most cases of neonatal conjunctivitis are relatively mild, self-limited and will not cause eye damage of any sort. However, if it left untreated it can lead to sight-treathening or even systemic complications.

• Neisseria gonorrhoea
• Chlamydia trachomatis is the most common cause of neonatal conjunctivitis

Common Causes

• Bacterial conjunctivitis
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Escherichia coli
  • Pseudomonas aeruginosa

• Viral conjunctivitis
  • Herpes simplex virus (HSV)
  • Varicella zoster virus (VZV)

Conjunctivitis in children

Life Threatening Causes

Most cases of conjunctivitis in children are relatively mild and self-limited, although untreated bacterial conjunctivitis may be associated with complications such as:

• keratitis
• Orbital cellulitis

Common causes

• Bacterial conjunctivitis
  • Haemophilus influenzae is the most common cause
  • Streptococcus pyogenes
  • Streptococcus pneumoniae

• Viral conjunctivitis
  • Adenovirus
  • HSV

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Newborn with suspected gonococcal conjunctivitis

❑ An urgent eye swab should be taken ❑ Urgent gram stain should be requested ❑ Polymerase chain reaction (PCR) can also be used ❑ Definitive diagnosis is made by subsequent bacteriological culture or Nucleic Acid Amplification Test (NAAT)

❑ Gram-negative intracellular diplococci is highly suggestive of gonococcal conjunctivitis

Further investigation including : ❑ Screening for other STDs in both mothers and neonates ❑ Genital and throat swabs in patients with risk factors

Complete Diagnostic Approach

Neonatal conjunctivitis

Ophthalmia neonatorum is essentially a clinical diagnosis made by observation of signs and symptoms.

Neonate with eye discharge

Take a full history and examine

❑ Bilateral or unilateral red eye ❑ Purulent discharge ❑ Eyelid swelling ❑ Chemosis

No

Yes

❑ Reassure mother ❑ Advise to return if not better

Culture for chlamydia and gonorrhea

Conjunctival swab for ❑ Gram stain ❑ Giemsa stain

Negative

Positive

HSV is suspected

❑ Oral antibiotics ❑ Treat mother and her partner

Conjunctivitis in children

Most cases are diagnosed on the basis of clinical features

Child with acute red eye

Discharge

No discharge

Purulent

Stringy or watery

Other symptoms and signs

Bacterial conjunctivitis

Allergic conjunctivitis or viral conjunctivitis

No

Yes

Trial of topical antibiotics

Advise self-limiting condition

Possible bacterial conjunctivitis

Refer to ophthalmologist

Treatment

Neonatal conjunctivitis

Ophthalmia neonatorum is an ocular emergency so all infants with neonatal conjunctivitis should be admitted.

Category	Symptoms	DDx	Treatment	Parents treatment
Gonococcal conjunctivitis	Mucopurulent discharge Eyelids swelling Chemosis	Congenital glaucoma Nasolacrimal duct obstruction Dacryocystitis	Ceftriaxone 25 mg/k to 50 mg/kg, max 125 mg IV or IM single dose Alternatively Cefotaxime 100 mg/kg IV or IM single dose Spectinomycin 25 mg/kg (maximum 75 mg) IM single dose Hourly saline lavage	Infected mother single dose of ceftriaxone (25-50 mg/kg)
Chlamydial conjunctivitis	Copious discharge Eyelids swelling Papillary reaction	Cellulitis Keratitis	Oral erythromycin syrup, 50 mg/kg/day, in 4 divided doses for 14 days Topical erythromycin or tetracycline	Infected mother Oral doxycycline 100 mg twice daily for 7 days or Azithromycin 1 g orally as a single dose
Herpetic conjunctivitis	Vesicles around the eye Corneal involvement Watery discharge	Keratitis Nasolacrimal duct obstruction	Low dose systemic acyclovir (30mg/kg/ day IV or Vidarabine 30 mg /kg/day IV for 2 weeks	Oral acyclovir 400 mg daily for 1 week

Conjunctivitis in children

In most cases, conjunctivitis is self-limited and some supportive treatment would be needed. However, some cases require medical intervention.

Category	Symptoms	Causes	Treatment
Bacterial conjunctivitis	Mucopurulent discharge Bilateral onset Chemosis	Haemophilus influenzae most common Streptococcus pneumoniae Moraxella catarrhalis less common	Azithromycin 1.5% ocular solution Polymyxin B with Trimethoprim sulfate 10,000 U, 1 mg/mL ophthalmic solution for 1 week Gentamicin 0.3% ophthalmic ointment for 1 week
Viral conjunctivitis	Watery discharge Unilateral onset Preauricular node	Adenovirus HSV	Ganciclovir 0.15% ophthlamic gel for 1 week Trifluridine 1% solution q4h for 1 week
Allergic conjunctivitis	Itching Watery discharge	Pollens	Topical mast cell stabilizers like diclofenacor ketorolac Topical antihistamines

Do's

• Neonatal conjunctivitis
  • The majority of newborns with conjunctivitis would be infected when pass through the birth canal. Hence, the most common strategies for preventing transmission seek to reduce neonatal exposure to active genital lesions.
  • All pregnant women aged <25 years and older women at increased risk for infection for instance those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has a sexually transmitted infection, should be routinely screened for chlamydia trachomatis and N.gonorrhea at the first prenatal visit.
  • Pregnant women found to have chlamydial infection should have a test-of-cure to document chlamydial eradication (preferably by nucleic acid amplification testing NAAT) 3–4 weeks after treatment and then retested within 3 months.
  • Women found to have gonococcal infection should be treated immediately and retested within 3 months.
  • Pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester to prevent maternal postnatal complications and gonococcal infection in the neonate.
  • Accurate risk assessment and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services.
  • In mother with active recurrent genital HSV lesions, antiviral suppressive therapy with oral acyclovir or valacyclovir can mitigate the risk of neonatal conjunctivitis.
  • Prophylaxis with silver nitrate 1% or erythromycin ointment 0.5% is part of the routine newborn care for ophthalmia neonatorum prevention.
• Conjunctivitis in children
  • In assessment of a child presenting with red eye, serious causes (such as acute glaucoma, keratitis, iritis and trauma must be excluded.
  • Reassuring the parents that most cases are self-limiting.
  • Advising self-care measures such as cleaning the eyelids, cool compresses, lubricating drops or artificial tears.
  • Any patient treated for suspected bacterial or viral conjunctivitis that does not improve significantly with initial therapy should be referred to an ophthalmologist for further evaluation.

Don'ts

• Do not share personal articles that come in contact with the eyes (e.g. eye make-up applicators, towels, wash cloths, eye droppers).
• Avoid vaginal delivery in mothers with STDs.