Initial therapy is based on the results of the Gram and Giemsa stains if they can be examined immediately. Therapy is then modified according to the culture results and clinical response.
- No information from stains, no particular organism suspected: Erythromycin ointment q.i.d. plus erythromycin elixir 50 mg/kg/d in four divided doses for 2 to 3 weeks.
- Suspect chemical (e.g., silver nitrate) toxicity: Discontinue offending agent. No treatment or preservative-free artificial tears q.i.d. Reevaluate in 24 hours.
- Suspect chlamydial infection: Erythromycin elixir 50 mg/kg/d orally in four divided doses for 14 days, plus erythromycin ointment q.i.d. Alternatively, azithromycin 20 mg/kg orally for 3 days can be used. Topical therapy alone is not effective. If confirmed by culture or immunofluorescent stain, treat the mother and her sexual partners with one of the following:
- Doxycycline 100 mg p.o. b.i.d. for 7 days (for women who are neither breastfeeding nor pregnant). If breastfeeding or pregnant, one of the following regimens may be used: azithromycin 1 g as a single dose, amoxicillin 500 mg p.o. t.i.d. for 7 days, or erythromycin 250 to 500 mg p.o. q.i.d. for 7 days.
- Suspect N. gonorrhoeae:
- Saline irrigation of the conjunctiva and fornices until discharge gone.
- Hospitalize and evaluate for disseminated gonococcal infection with careful physical examination (especially of the joints). Blood and cerebrospinal fluid cultures are obtained if a culture-proven infection is present.
- Ceftriaxone 25 to 50 mg/kg intravenously (i.v.) or intramuscularly (i.m.) (not to exceed 125 mg) as a single dose or cefotaxime 100 mg/kg i.v. or i.m. as a single dose. In penicillin-allergic patients or cephalosporin-allergic patients, an infectious disease consult is recommended. If sensitivities are not initially available, ceftriaxone is the treatment of choice. Systemic antibiotics sufficiently treat gonococcal conjunctivitis, and topical antibiotics are not necessary.
- Topical saline lavage q.i.d. to remove any discharge.
- All neonates with gonorrhea should also be treated for chlamydial infection with erythromycin elixir 50 mg/kg/d in four divided doses for 14 days.
- Gram-positive bacteria with no suspicion of gonorrhea and no corneal involvement: Bacitracin ointment q.i.d. for 2 weeks.
- Gram-negative bacteria with no suspicion of gonorrhea and no corneal involvement: Gentamicin, tobramycin, or ciprofloxacin ointment q.i.d. for 2 weeks.
- Bacteria on Gram stain and corneal involvement: Hospitalize, workup, and treat as discussed in 4.11, BACTERIAL KERATITIS.
- Suspect herpes simplex virus: The neonate (under 1 month of age), regardless of the presenting ocular findings, should be treated with acyclovir intravenously as well as with vidarabine 3% ointment five times per day or ganciclovir 0.15% gel five times per day or trifluridine 1% drops nine times per day. Prompt initiation of intravenous acyclovir may prevent dissemination of the HSV infection and spread to the CNS. Topical therapy is optional when systemic therapy is instituted. In full-term infants, the dosage for acyclovir is 60 mg/kg/d divided into three doses. If infection is limited to the skin, eye, and mouth, it is administered intravenously for 14 days. Treatment duration is extended to 21 days if the disease is disseminated or involves the central nervous system. Consultation with a pediatric infectious disease specialist is recommended. For children with recurrent ocular lesions, oral suppressive therapy with acyclovir (20 mg/kg b.i.d.) may be of benefit.
NOTE: |
Inadequately treated chlamydial conjunctivitis in a neonate can lead to chlamydial otitis or pneumonia. |
NOTE: |
All neonates with chlamydial infection should also be evaluated for N. gonorrhoeae infection. |
NOTE: |
If confirmed by culture, the mother and her sexual partners should be treated appropriately for both gonorrhea and chlamydia infections. |