Sexually transmitted infections and HIV in ophthalmology.

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Severe ophthalmia neonatorum in Southwest China: a 5-year review of demographics, microbiological results, and risk factors.

PURPOSE: To evaluate the microbiological characteristics and risk factors of severe ophthalmia neonatorum (ON) in Southwest China. METHODS: In this retrospective review, data on demography, microbiological results, and risk factors were analyzed. Data were obtained from medical records of patients with severe ON treated at Children's Hospital of Chongqing Medical University from January 2015 to December 2019. To understand the risk factors for severe ON, maternal and neonatal factors were compared between the severe and non-severe ON groups. RESULTS: A total of 1397 neonates with ON were included, of whom 12% (n = 172) had severe ON, and 88% (n = 1225) had non-severe ON. Microbial detection and drug susceptibility tests were performed on 169 patients with severe ON. Culture results were positive for 76 patients, with gram-positive bacteria in 71.1% (n = 54), gram-negative bacteria in 25.0% (n = 19), and multiple microorganisms in 3.9% (n = 3) neonates. The most commonly detected organisms were Staphylococcus aureus (29%) and Staph. epidermis (27%), followed by Escherichia coli (8%). Neisseria gonorrhea (8%), Moraxella catarrhal (5%), Streptococcus pneumoniae (4%), Haemophilus influenza (4%), and Chlamydia trachomatis (1%). The main risk factors for severe ON were obstruction of the nasolacrimal duct (χ2 = 10.794, P = 0.001), meconium aspiration syndrome (χ2 = 6.252, P = 0.012), and cesarian section (χ2 = 5.118, P = 0.024). Neonatal ocular prophylaxis was a protective factor for severe conjunctivitis (χ2 = 6.905, P = 0.009). CONCLUSIONS: Staphylococcus is the most common pathogen of severe ON. Nasolacrimal duct obstruction (NLDO) is a risk factor for ON.

Adverse pregnancy and neonatal outcomes associated with Neisseria gonorrhoeae: systematic review and meta-analysis.

OBJECTIVE: To examine associations between Neisseria gonorrhoeae (NG) infection during pregnancy and the risk of preterm birth, spontaneous abortion, premature rupture of membranes, perinatal mortality, low birth weight and ophthalmia neonatorum. DATA SOURCES: We searched Medline, EMBASE, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature for studies published between 1948 and 14 January 2020. METHODS: Studies were included if they reported testing for NG during pregnancy and compared pregnancy, perinatal and/or neonatal outcomes between women with and without NG. Two reviewers independently assessed papers for inclusion and extracted data. Risk of bias was assessed using established checklists for each study design. Summary ORs with 95% CIs were generated using random effects models for both crude and, where available, adjusted associations. RESULTS: We identified 2593 records and included 30 in meta-analyses. Women with NG were more likely to experience preterm birth (OR 1.55, 95% CI 1.21 to 1.99, n=18 studies); premature rupture of membranes (OR 1.41, 95% CI 1.02 to 1.92, n=9); perinatal mortality (OR 2.16, 95% CI 1.35 to 3.46, n=9); low birth weight (OR 1.66, 95% CI 1.12 to 2.48, n=8) and ophthalmia neonatorum (OR 4.21, 95% CI 1.36 to 13.04, n=6). Summary adjusted ORs were, for preterm birth 1.90 (95% CI 1.14 to 3.19, n=5) and for low birth weight 1.48 (95% CI 0.79 to 2.77, n=4). In studies with a multivariable analysis, age was the variable most commonly adjusted for. NG was more strongly associated with preterm birth in low-income and middle-income countries (OR 2.21, 95% CI 1.40 to 3.48, n=7) than in high-income countries (OR 1.38, 95% CI 1.04 to 1.83, n=11). CONCLUSIONS: NG is associated with a number of adverse pregnancy and newborn outcomes. Further research should be done to determine the role of NG in different perinatal mortality outcomes because interventions that reduce mortality will have the greatest impact on reducing the burden of disease in low-income and middle-income countries. PROSPERO REGISTRATION NUMBER: CRD42016050962.

A five-year study in Iran of ophthalmia neonatorum: prevalence and etiology.

BACKGROUND: The aim was to determine the prevalence of conjunctivitis and its bacteriological causes in neonates hospitalized in two hospitals in Iran and to evaluate the maternal and newborns' data in conjunctivitis cases. MATERIAL/METHODS: All newborns presenting at Imam Khomeini and Vali-e-Asr hospitals (2001-2006) with clinical suspicion of conjunctivitis and positive microbiology were studied. The medical files of those with conjunctivitis were assessed. RESULTS: Of 4021 neonates examined for the presence of conjunctivitis, 198 (4.9%) had conjunctivitis. Sixty-five percent of the cases had been delivered by cesarean section, 47% and 11% had histories of maternal premature rupture of membrane (PROM) and genitourinary infection, respectively, 65% were preterm, and 61% and 32% had low weight and APGAR score below 7 at birth, respectively. In addition, 22% had septicemia. The most common organism causing ophthalmia was S. aureus (31%), followed by E. coli (23%), S. epidermis (22%), Klebsiella (10%), N. gonorrhea (3%), C. trachomatis (2%), and Pseudomonas aeruginosa (2%). In the neonates with septicemia the most common cause of conjunctivitis was E. coli (38%). Neonates with E. coli conjunctivitis had a significantly (P<0.05) higher rate of a history of maternal genitourinary infection and a higher rate of septicemia than non-E. coli cases. CONCLUSIONS: The prevalence of 4.9% found here is consistent with other reports ranging from 1.6 to 12% of neonates. Data such as birth weight, APGAR score, presence of septicemia, maternal genitourinary infections, and PROM may play a role in the development of neonatal conjunctivitis by different pathogens.

Conjuntivitis postnatal en un paciente premature causada por cytomegalovirus / Cytomegalovirus induced postnatal conjunctivitis in a premature patient

El citomegalovirus (CMV) constituye en la actualidad el principal virus causante de infecciones congénitas, neonatales y perinatales en la población pediátrica sana. La conjuntivitis por CMV es una entidad muy poco frecuente apenas recogida en la literatura. Se presenta ocasionalmente en niños inmunodepremidos con procesos leucémicos. También se ha podido detectar la presencia de CMV en las lágrimas de pacientes con mononucleosis por CMV, enfermos de SIDA y pacientes sometidos a trasplante renal. Se presenta un caso de conjuntivitis neonatal en un paciente con presencia del virus en el tracto respiratorio y orina. Debido a que el proceso inflamatorio y el aislamiento viral sólo se detectó en un ojo, se postula la posibilidad de que el proceso de autoinoculación a través de las manos del paciente sea la causa del proceso (AU)

Cytomegalovirus (CMV) is actually the principal viral etiological agent of congenital, neonatal and perinatal infections in healthy pediatric patients. The conjunctivitis caused by CMV is an infrequent pathology described in the literature. This entity has been occasionally described inimmunossuppresed children with leukemic processes. The virus could be detected in the tears of CMV mononucleosis children, AIDS patients and patients with kidney transplants. We report a neonatal CMV conjunctivitis in a child with this virus in the respiratory tract and urine. Because the inflammatory process and the viral isolation could be detected in one eye only, we postulated that the auto-inoculation, with hands, could be the cause of the conjunctivitis process (AU)

Neonatal chlamydial infections: prevention and treatment.

Neonatal chlamydial infection, which manifests principally as ophthalmia neonatorum (ON) or pneumonia, is a significant cause of neonatal morbidity. Widespread use of silver nitrate drops resulted in a dramatic decline in the incidence of gonococcal ophthalmia but had much less impact on the incidence of neonatal chlamydial infection. Chlamydia trachomatis has become the most common infectious cause of ON in developed countries.A number of prophylactic antibiotic or antiseptic agents have been used to prevent ON. Prophylaxis with 1% silver nitrate ophthalmic drops, 0.5% erythromycin ophthalmic ointment, or 1% tetracycline ointment has comparable efficacy for the prevention of chlamydial ophthalmia but does not offer protection against nasopharyngeal colonization or the development of pneumonia. Erythromycin or tetracycline topically have been used as prophylactic agents because of their allegedly superior activity for the prevention of ON and because they produced less chemical conjunctivitis compared with silver nitrate. However, the relative efficacy of these agents for chlamydial infection and the emergence of beta-lactamase-producing Neisseria gonorrheae has raised questions regarding their effectiveness when applied topically for prophylaxis of ON. Compared with these agents, a 2.5% povidone-iodine ophthalmic solution has been found to have greater efficacy for the prevention of ON generally, and chlamydial ophthalmia specifically. In countries where the incidence of ON is very low, an alternative strategy is to institute prenatal screening and treatment of infected mothers, forgo routine neonatal prophylaxis, and follow-up infants after birth for the possible development of infection. For the treatment of chlamydial ophthalmia or pneumonia, oral erythromycin for 2 weeks is recommended; additional topical therapy is unnecessary. However, in approximately 20-30% of infants, therapy will not eradicate the organism and the infant may require a repeat oral course of antibiotics. The few published studies on the use of the new oral macrolide antibiotics, such as azithromycin, roxithromycin, or clarithromycin for chlamydial infections in neonates suggest that these agents may be effective; however, more data on their tolerability and efficacy in this patient group are warranted.

Transferring policies for treating sexually transmitted infections: what's wrong with global guidelines?

The paper uses a case study of the development of syndromic management for treating sexually transmitted infections (STIs) and subsequent policies recommending worldwide use of syndromic management guidelines. These treatment policies emerged in the late 1970s from researchers and public health physicians working in sub-Saharan Africa where they had to treat large numbers of STIs in difficult circumstances. Syndromic management was initially developed in specific local epidemiological and resource situations. By the late 1980s, the World Health Organization had adopted syndromic management as policy, and began to promote it globally in the form of algorithms and training guidelines. Dissemination was assisted by the context of the rapid spread of HIV/AIDS and the apparent effectiveness of syndromic management for treating STIs and slowing the transmission of HIV/AIDS. In the mid 1990s, international donors interested in HIV control and women's reproductive health took it up, and encouraged national programmes to adopt the new guidelines. Implementation, however, was a great deal more complex than anticipated, and was exacerbated by differences between three rather separate policy networks involved in the dissemination and execution of the global guidelines. The analysis focuses on two parts of the process of policy transfer: the organic development of scientific and medical consensus around a new policy for the treatment of STIs; and the formulation and subsequent dissemination of international policy guidelines. Using a political science approach, we analyze the transition from clinical tools to global guidelines, and the associated debates that accompanied their use. Finally, we comment on the way current global guidelines need to be adapted, given the growth in knowledge.

Prophylaxis of ophthalmia neonatorum--a nationwide survey of the current practice in Austria.

UNLABELLED: The aim of this study was to analyze the current practice of Ophthalmia neonatorum prophylaxis in Austria. Questionnaires were sent to 107 hospitals with obstetric units, as well as to 490 registered community midwives, together looking after a yearly total of approximately 70,000 births. The overall return of the hospitals and midwives was 91.6% and 7.6%, respectively. RESULTS: Ophthalmia neonatorum prophylaxis is being applied by 93.8% of all respondents (hospitals 96.9%, and community midwives 82.3%). The three most frequently applied substances were Erythromycin (41.8%), Gentamicin (21.3%) and Silver nitrate (19.7%). Other substances were Tetracycline, Povidone-Iodine, Neomycin and Chloramphenicol. The reported overall-observation of chemical conjunctivitis after application of a prophylactic agent was 42.3% (55/133), typically after the use of Silver nitrate, Erythromycin or Tetracycline. The agent was determined by pediatricians (29%), in accordance to governmental decree (15%), by hospital policy (12%), effectiveness against Chlamydia and Gonococci (9%), by pharmacists (3%) and ophthalmologists (3%). 18% did not give any reason for the choice of agent. CONCLUSION: The rationale for prophylaxis and the substances used in Austria show heterogeneity. Seven prophylactic agents are used, two antiseptics and five antibiotics. 25% of the routine applicants are using substances (Gentamicin, Neomycin or Chloramphenicol) for which no evidence based efficacy for prophylaxis of Ophthalmia neonatorum has been demonstrated through clinical trials. However, 83.5% of the maternity units do not want changes in their current routine, unless there is a nation-wide agreement for Ophthalmia neonatorum prophylaxis.

An uncommon cause of ophthalmia neonatorum: Neisseria meningitidis.

Ophthalmia neonatorum is defined as conjunctivitis appearing during the first month of life. The differential diagnosis includes chemical, bacterial, viral, and other pathogens, including Neisseria gonorrhoeae, herpes simplex, and Chlamydia trachomatis. Neisseria meningitidis is not commonly specifically included in the differential.

The influence of perinatal infective factors on ophthalmia neonatorum.

BACKGROUND: Ophthalmia neonatorum still blinds approximately 10,000 babies annually worldwide. Identification of contributory maternal perinatal factors could possibly predict which babies are at greater risk for this disease. METHODS: In a randomized prospective study of ophthalmia neonatorum in Kenya, we studied the effect of prophylaxis with povidone-iodine, silver nitrate, and erythromycin in 3117 neonates. Four perinatal factors that may promote ophthalmia neonatorum were investigated: maternal vaginitis, birth in a nonsterile environment, presence of meconium at birth, and postnatal development of endometritis. RESULTS: No significant difference in the general ophthalmia neonatorum rate was found for any of the four factors (P > .14 by Fisher exact test). However, with regard to venereal ophthalmia neonatorum, the 26 infants born to mothers with vaginitis had a relative risk 5.1 times that of the rest of the infants (P = 0.0013). Their relative risk to develop gonococcal ophthalmia neonatorum in particular was 24.9 times the rest of the neonates (P = 0.0000031). Prophylaxis was with povidone-iodine in 12 infants, silver nitrate in two, and erythromycin in 12. The frequency of ophthalmia neonatorum was 25%, 100%, and 33%, respectively (differences not significant). CONCLUSION: Neonates born to mothers with vaginitis should be carefully observed for the first postnatal month for the development of ophthalmia neonatorum, even though a prophylactic agent has been used.

Ophthalmia neonatorum in the United Arab Emirates.

Ophthalmia neonatorum in small babies is a common problem in neonatal units in Al Ain, but is infrequently associated with sexually transmitted disease agents. A study of 81 babies with ophthalmia neonatorum showed that 81.5% had bacterial or fungal infections. Staphylococcus aureus was the commonest causative organism followed by Escherichia coli and Pseudomonas aeruginosa while Chlamydia trachomatis and Neisseria gonorrhoeae were responsible for less than 5% of all cases. The disease was predominantly mild to moderately severe and easily treated with topical broad-spectrum antibiotic agents which are effective against Gram-positive and Gram-negative bacteria, including hospital-associated strains. The most effective antimicrobial agents were gentamicin topically or ceftriaxone systemically.

PIP: Neonatal conjunctivitis is common in many developing countries, often due to a sexually transmitted disease (STD) such as Chlamydia trachomatis and Neisseria gonorrhoea. The prevention of ophthalmia neonatorum (ON) depends considerably upon knowledge of the type and incidence of the causative organisms, just as the recommended treatment protocols for ON vary according to the local causative microorganisms and their sensitivity to available antimicrobial agents. ON is a common problem in the neonatal units of Al Ain, but infrequently associated with STD agents. A study found 81.5% of 81 babies with ON to have either bacterial or fungal infections. Staphylococcus aureus was the most common causative organism followed by Escherichia coli and Pseudomonas aeruginosa. Chlamydia trachomatis and Neisseria gonorrhoea were responsible for less than 5% of all cases. The disease was mainly mild to moderately severe and easily treated with topical broad-spectrum antibiotic agents effective against Gram-positive and Gram-negative bacteria, including hospital-associated strains. The most effective antimicrobial agents were gentamicin topically and ceftriaxone systemically.

Ophthalmia neonatorum in a trachoma endemic area.

BACKGROUND AND OBJECTIVES: Chlamydia trachomatis can be directly transmitted by sexual or perinatal contact and indirectly transmitted by flies or fomites. Whether distinct epidemiologic forces among human populations or biologic characteristics of the organism are responsible for the different routes of transmission is uncertain. STUDY DESIGN: To determine if ophthalmia neonatorum and trachoma are linked epidemiologically, 38 infants with ophthalmia and 277 children with trachoma were studied for evidence of C. trachomatis infection using culture, antigen and DNA detection tests. The study was performed in a trachoma endemic area of central Kenya. RESULTS: Of infants with ophthalmia neonatorum, 8% to 9% had microbiologic evidence of ocular C. trachomatis infection. Of the children with trachoma, 31% had evidence of chlamydial infection. Ninety-two percent of the 59 identified strains causing trachoma belonged to the classic trachoma serovars (A, B, Ba and C). Neither of the two chlamydial strains recovered from infants with ophthalmia was a trachoma serovar. Mothers rarely (3%) had cervical C. trachomatis infection. CONCLUSION: This study does not support a major role for perinatally transmitted C. trachomatis infection in trachoma epidemiology.

PIP: Chlamydia trachomatis can be directly transmitted by sexual or perinatal contact and indirectly by flies or fomites. To determine if ophthalmia neonatorum and trachoma are linked epidemiologically, 38 infants with ophthalmia (mean age of 1.8 +or- 2.5 months) and 277 children with trachoma (3 months - 14 years old) were studied for evidence of C trachomatis infection using culture, antigen, and DNA detection tests. The study was performed in a trachoma endemic area in 2 rural health centers (Lare and Mutuwati) in the Meru District in central Kenya over a 2 1/2-year period between 1988-1991. 29 mothers of the 38 infants had tests for cervical C. trachomatis infection. 53 children with trachomatous inflammation (follicular) (TF) and 224 children with trachoma inflammation (intense) with or without TF were enrolled. Subjects were classified according to the World Health Organization trachoma grading scheme. 167 mothers of these 277 children were examined for evidence of cervical C trachomatis infection. Of infants with ophthalmia neonatorum, 8-9% had microbiologic evidence of ocular G trachomatis infection. Of the children with trachoma, 31% had evidence of chlamydial infection. 92% of the 59 identified strains causing trachoma belonged to the classic trachoma serovars (A, B, Ba and C). 3% of mothers had cervical C trachomatis infection. Among children with trachoma, 10% had positive ocular cultures for C. trachomatis, 24 had positive EIA tests, and 31% had positive PCR tests. Among infants with ophthalmia neonatorum, evidence of C. trachomatis infection was rare. 9% (2 of 22) had positive EIA tests, and 8% (2 of 26) had positive PCR tests. Among the mothers of children with trachoma, 3% had positive C. trachomatis cervical cultures and 2% had positive EIA tests. No mother of an infant with ophthalmia neonatorum had positive cervical tests for C. trachomatis. There was no evidence of a major role for perinatally transmitted C trachomatis infection in trachoma epidemiology.

Ophthalmia neonatorum.

Ophthalmia neonatorum is the most common infection in the first month of life and can have serious systemic as well as ophthalmic morbidity. This article discusses the differential diagnosis and treatment of conjunctivitis in the neonate. Controversies in method of prophylaxis are reviewed.