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Referral and warning signs
When to refer
Refer to hospital/paediatrician for inpatient management and systemic antibiotics. Urgent ophthalmology consultation if corneal involvement (clouding, ulceration) is suspected.
Red flags
- Corneal clouding or opacity
- Suspected corneal ulcer
- Poor response to initial treatment
- Signs of systemic illness in the neonate
Signs and symptoms
- Purulent eye discharge (often copious and bilateral, especially with Gonorrhoea)
- Eyelid swelling (edema)
- Conjunctival redness (injection) and chemosis (swelling)
- Onset typically within first few days of life (Gonorrhoea) or 5-14 days (Chlamydia), but can occur up to 30 days.
- Corneal clouding or ulceration (potential complication)
Risk factors
- Untreated maternal Gonorrhoea or Chlamydia infection
- Lack of antenatal screening/treatment for STIs
- Failure to apply prophylactic eye ointment at birth
- Premature rupture of membranes
- Difficult labour/assisted delivery
Diagnosis
Clinical assessment
Clinical suspicion based on purulent conjunctivitis in a neonate. Examination reveals discharge, lid swelling, conjunctival injection.
Investigations
- Conjunctival swab/scraping: Gram stain (look for Gram-negative intracellular diplococci - Gonorrhoea), Giemsa stain (look for Chlamydial inclusion bodies), Culture for N. gonorrhoeae, PCR/NAAT for N. gonorrhoeae and C. trachomatis (preferred if available).
Diagnostic criteria
Clinical presentation of purulent conjunctivitis in a neonate <30 days old.
Management
Non-pharmacological management
- Gentle eye cleaning with sterile saline or water to remove discharge.
- Use gloves and wash hands thoroughly when handling infant's eyes.
- Cover unaffected eye if only one is involved during cleaning.
Pharmacological treatment
- Systemic treatment is essential to cover both Gonorrhoea and Chlamydia:
- - Ceftriaxone 125 mg IM single dose (covers Gonorrhoea). (Some guidelines recommend 25-50 mg/kg, max 125mg).
- - PLUS Azithromycin syrup 20 mg/kg PO once daily for 3 days (covers Chlamydia). (Alternative: Erythromycin syrup 50 mg/kg/day divided QID for 14 days).
- - Topical antibiotics (e.g., tetracycline ointment) alone are INADEQUATE for treatment but may be used adjunctively after initial cleaning while awaiting/starting systemic therapy.
- - Treat both parents for Gonorrhoea and Chlamydia according to adult STI guidelines.
- - Screen parents for Syphilis and HIV.
Monitoring
Monitor for resolution of discharge and inflammation. Assess cornea for clarity.
Complications
- Corneal ulceration
- Corneal scarring/opacity
- Corneal perforation
- Blindness
- Systemic infection (Gonococcal: sepsis, arthritis, meningitis; Chlamydial: pneumonia)
Prevention
- Antenatal screening and treatment of pregnant women for Gonorrhoea, Chlamydia, and Syphilis.
- Application of prophylactic eye ointment (e.g., Tetracycline 1% or Erythromycin 0.5%) to both eyes of ALL newborns immediately after birth.
Patient education
- Explain the serious nature of the infection and the risk of blindness.
- Stress the importance of completing the full course of systemic antibiotics for the baby.
- Explain the need for both parents to be treated for STIs.
- Demonstrate proper eye cleaning technique.
- Advise on signs of worsening or complications requiring immediate return.
Uganda-specific notes
Ophthalmia neonatorum is a preventable cause of blindness. Universal application of prophylactic tetracycline eye ointment at birth is policy. Systemic treatment with Ceftriaxone + Azithromycin/Erythromycin is crucial. Treat parents.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.9.1