Gonorrheal conjunctivitis
Background
- Caused by Neisseria gonorrhoeae
- Usually spread from genital-hand-eye contact in the young sexually active population
- Neonates can acquire it from the birth canal
Clinical features
- Abrupt onset
- Copious purulent discharge (reforms quickly after wiping away)
- Marked conjunctival injection/chemosis
- Lid swelling
- Globe tenderness through closed lids
- Preauricular lymphadenopathy
- May or may not be associated with features of urethritis
Neonates
- 3-5 days postpartum
- Bilateral discharge
- May be localized to other organs (arthritis, meningitis, pneumonia) or may be disseminated
Differential Diagnosis
Evaluation
- Gram staining for gram-negative diplococci
- Cultures for Neisseria
Management
- Treatment for bacterial organisms is targeted toward S. aureus, S. pneumoniae, H. influenzae, Pseudomonas, N. gonorrhea, C. trachomatis
- Contact lens wearers should be given coverage for pseudomonas with one of the fluoroquinolone drops
Bacterial Conjunctivitis
- Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
These options do not cover gonococcal or chlamydial infections
- Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
- Erythromycin applied to the conjunctiva q6hrs for 7 days OR
- Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
- Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
- Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
- Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment
Chlamydial
- Doxycycline 100mg PO BID for 7 days OR
- Azithromycin 1g (20mg/kg) PO one time dose
- Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days
- Disease manifests 5 days post-birth to 2 weeks (late onset)
Gonococcal
- Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
- Ceftriaxone 250mg IM one dose PLUS
- Azithromycin 1g PO one dose
- Newborn Treatment:
- Prophylaxis: Erythromycin ophthalmic 0.5% x1
- Disease manifests 1st 5 days post delivery (early onset)
- Treatment Ceftriaxone 25-50mg IV or IM, max 125mg
- Eye irrigation (saline)
- Systemic antibiotics for gonorrhea
- Urgent referral to ophtho
Disposition
- Infant=Admit?
- Adult=Discharge
- Unless evidence of complication or immunodeficiency
Complications
- Ulceration
- Perforation
See Also
- Conjunctivitis
- Sexually Transmitted Diseases (STD)
References
Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin N Am. 2008;26:35-55. [{Category:ID]]
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