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  1. Problem. A purulent eye discharge is noted in a 3-day-old infant. Conjunctivitis is the most common neonatal infection.

  2. Immediate questions

      1. How old is the infant? Age is important in determining the cause of eye discharge. In the first 6–24 h of life, conjunctivitis due to ocular silver nitrate drops immediately after birth is most likely. At 2–5 days, a bacterial infection is most likely. The organisms most common in the neonatal period are Neisseria gonorrhoeae and Staphylococcus aureus. Chlamydia trachomatis conjunctivitis is usually seen after the first week of life (5–14 days) and often presents as late as the second or third week. Herpes conjunctivitis is seen 5–14 days after birth. Pseudomonas aeruginosa infections are typically seen between 5 and 18 days of life.

      1. Is the discharge unilateral or bilateral? Bilateral conjunctivitis is seen with infection caused by C. trachomatis or N. gonorrhoeae or by the use of silver nitrate. Unilateral conjunctivitis is most often seen with S. aureus,P. aeruginosa, and herpes simplex. Lacrimal duct obstruction causes unilateral discharge.

      1. What are the characteristics of the discharge? Distinguish purulent from watery discharge. Purulent discharge is more common with bacterial infection. Chlamydia infection is watery early and purulent later. Greenish discharge is more characteristic of P. aeruginosa.Herpes conjunctivitis usually has a nonpurulent and serosanguineous discharge. Gonorrhea has a purulent discharge. A blood-stained discharge is highly specific for Chlamydia.

      1. Does the mother have a history of sexually transmitted diseases? Infants that pass through the birth canal of an infected mother with gonorrhea or Chlamydia have an increased conjunctivitis risk.

  3. Differential diagnosis. Eye discharge can be infectious or inflammatory or due to obstruction. Other diagnoses that may mimic conjunctivitis and need to be ruled out are foreign body, lacrimal duct obstruction, eye trauma, and glaucoma. Conjunctivitis in the neonate is either infectious (bacterial, viral, or chlamydial) or secondary to a chemical response. Conjunctivitis in the newborn is caused by: C. trachomatis (2–40%), N. gonorrhoeae (<1%), herpes simplex (<1% of cases), chemical (due to silver nitrate use), and other bacterial microbes (30–50%). These other microbes include Staphylococcus species, S. pneumoniae,Haemophilus influenzae, Streptococcus mitis, group A and B streptococci, Enterobacter, Acinetobacter, Neisseria cinerea, Corynebacterium species, Moraxella catarrhalis, Escherichia coli, Klebsiella pneumoniae, and P. aeruginosa. One study revealed that 56% of conjunctivitis cases were infectious (Chlamydia most common) and 44% were of uncertain origin.

      1. Chemical conjunctivitis is usually secondary to silver nitrate ocular drops and is the most common cause of conjunctivitis in underdeveloped countries. It is less common now with erythromycin ophthalmic ointment, which is less irritating. Prophylaxis with erythromycin does not prevent neonatal chlamydial conjunctivitis. Silver nitrate is recommended over erythromycin if the patient population has a high number of penicillinase-producing N. gonorrhoeae. Povidone-iodine 2.5% is being used in some underdeveloped countries now for ophthalmia neonatorum prophylaxis.

      1. Gonococcal conjunctivitis is most commonly transmitted from the mother during vaginal birth. The eyes are very red with a thick purulent drainage and swelling. This is an emergency because, left untreated, it can cause corneal ...

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