Conjunctivitis in the newborn infant usually is due to chemical and mechanical irritation caused by the instillation of silver nitrate drops or ointment into the eye in order to prevent gonorrheal ophthalmia. Chemical conjunctivitis differs from infective forms in that it becomes apparent almost immediately after the instillation. The most common causes of infectious conjunctivitis in descending order of frequency are Chlamydia trachomatis, Neisseria gonorrhoeae, Staphylococcus spp., inclusion conjunctivitis caused by groups A and B Streptococcus, Enterococcus spp., Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, E. coli, Moraxella catarrhalis, Neisseria meningitidis, Corynebacterium diphtheriae, herpes simplex virus, echoviruses, and Mycoplasma hominis (18). Clostridia and peptostreptococci were also implicated as probable causes of neonatal conjunctivitis (19).
The classical ophthalmia neonatorum caused by N. gonorrhoeae is an acute purulent conjunctivitis that appears from two to five days after birth. If untreated, the infection progresses rapidly until the eye becomes puffy and the conjunctiva is intensely red and swollen. The subsequent outcome would be corneal ulceration. Ophthalmia caused by organisms other than gonococcus, including Clostridium spp., occurs usually from 5 to 14 days following delivery, is indistinguishable clinically, and the conjunctival inflammatory reaction usually is milder than in ophthalmia caused by gonococci.
Isenberg et al. (20) who studied 106 infants, 50 delivered by cesarian section, and 56 delivered vaginally illustrated that those delivered by cesarean section had significantly fewer bacterial species and total number of organisms per subject than the infants delivered vaginally. The conjunctivae of infants delivered vaginally had significantly more bacteria characteristic of vaginal flora.
The conjunctiva of newborns acquires facultative and anaerobic bacteria during birth primarily from the mother's cervical flora during passage through the birth canal (14). The role of anaerobes in neonatal conjunctivitis was investigated by obtaining conjunctival cultures from 35 babies prior to silver nitrate application and 48 hours later (19). On initial culture, 46 facultative bacteria, and 27 anaerobes were recovered. The organisms isolated in almost all of these cases were present also in the mother's cervical cultures and in the baby's gastric aspirates, taken concomitantly. Clostridium spp. were recovered from two infants who developed conjunctivitis (14,19).
Clostridium perfringens was recovered from one newborn, and Clostridium bifermentans with Peptostreptococcus spp. were recovered from the other infant. Similar organisms were also recovered from the mother's cervix immediately after delivery. These infections were noted on the second and third day postdelivery. The conjunctivitis was characterized by a profuse yellow-green discharge and the eyelids were edematous in both newborns, and there were no other abnormal findings. Local therapy was initiated with 2% penicillin eye drops (two drops every two hours). The conjunctivitis subsided within three days, and repeat cultures of the eyes after 10 days were sterile. The babies were followed for three months with no residual of infection noted.
Of considerable interest is the change in the conjunctival flora after 48 hours. Gardnerella vaginalis, Bacteroides spp., and anaerobic cocci all but disappeared, whereas Staphylococcus epidermidis, Micrococcus spp., and Propionibacterium acnes increased in numbers. It is obvious that the conjunctiva of the newborn can be exposed to not only N. gonorrhoeae, but to other potentially pathogenic bacteria as well. However, most of those organisms disappeared from the conjunctiva within 48 hours.
Streptococcus mitis, a microaerophilic organisms that is part of the vaginal flora was associated with increased risk of conjunctivitis in newborns (21).
Of interest is that the silver nitrate solution of 1% currently used in newborns was efficacious in preventing in vitro growth of clostridia. However, in a concentration of 0.1% or lower, it was only bacteriostatic or ineffective (19). The common practice of rinsing the eyes with distilled water after the addition of silver nitrate to prevent chemical conjunctivitis may alter the ability of this solution to effectively inhibit certain strains of Clostridium spp.
Because anaerobic bacteria have been recovered from children (22) and adults (23,24) suffering from bacterial conjunctivitis, their presence in neonatal conjunctivitis is not surprising. These organisms, however, are not the most prevalent cause of inflammation of the eye in these age groups. Their presence should be suspected in children whose aerobic and chlamydial cultures are negative, in those who do not respond to conventional antimicrobial therapy, and in those at high risk of developing anaerobic infection (i.e., the presence of maternal amnionitis or premature rupture of membranes).
The experience acquired from the documented cases of anaerobic conjunctivitis indicates that local therapy with appropriate antimicrobial agents is generally adequate.
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