You are an FY2 in Paediatrics.
Miss Jane Jackson, aged 26, having 10 days old boy (Peter Jackson) with (chlamydia) infection in the eyes. He was admitted and after 3 days treatment, he was discharged with his father. Swab has been taken from the eyes and Chloramphenicol eye drop is being given to the boy. Mother is here to discuss the results of the swab.
Talk to the mother and address her concern.
D: Hello, how can I help you today?
P: I have come for the results of the swab taken from my son’s eye.
D: Okay, I have the results with me, but before I proceed let me ask you a few questions, so that I would be in a better position to answer everything you need.
P: Okay.
D: Could you please confirm the age of your son?
P: He is 10 days old.
D: Why did you bring your son to the hospital?
P: He was having red and sticky eyes
D:Is it in one eye or in both the eyes?
D: May I know since when?
P: For the last 3 days.
D: Any other symptoms?
P: No
D: Did he have any kind of discharge from the eyes?
P: Yes/No (If yes elaborate colour, quantity, smell, time of the day, early morning/especially after sleep)
D: Any swelling of the eyelids?
D: Any swelling or redness around the eyes?
D: Any fever?
D: Any neck stiffness or pain while moving the neck?
D: Any shyness towards light?
D: Is he drowsy or tired?
D: Any cough or phlegm?
D: Any breathing difficulty?
D: Did you notice any health-related problems in these 10 days?
D: Is he allergic to anything?
D: Have you or his father ever had any medical conditions?
D: Is he feeding well?
D: What do you feed him? D: How is his wee and poo?
D: Thank you for answering all my questions.
P: Could you please tell me about the results
D: Yes. We have done the swab to check which type of bug has caused him this eye infection. Unfortunately, the swab results came back positive for a bacteria called Chlamydia. We call this condition Ophthalmia Neonatorum. It can happen in the first 28 days after birth.
D: As the swab is positive for Chlamydia, we need to treat him with oral antibiotics (Erythromycin or Azithromycin) for 2 weeks to treat the infection completely and to prevent the complications.
P: But, why did he have this infection?
D: If you have chlamydia that’s not treated while you’re pregnant, there’s a chance you could pass the infection on to your baby during the delivery.
P: But I don’t have any symptoms?
D: Most people who have chlamydia don’t notice any symptoms. For some people they don’t develop until many months later. Sometimes the symptoms can disappear after a few days. Even if the symptoms disappear you may still have the infection and be able to pass it on.
D: Chlamydia is a sexually transmitted bacterium, that means this bug is transmitted by having unprotected sex.
D: Let me ask you a few questions to see if you have had this infection? Have you or your partner ever been diagnosed with STIs?
P: No
D: Did you ever have symptoms like pain when urinating or unusual vaginal discharge or pain in the tummy or pelvis?
P: No
D: Any pain during sex?
P: No
D: Any bleeding after sex or bleeding between periods?
P: No
D: Multiple sexual partners increases the risk of STIs. Have you had any other sexual partners before?
P: No dr, I only have one sexual partner from the last 2/3 years.
P: Dr, does this mean my partner is cheating on me, because I have only one sexual partner?
D: As you told me that you only have one sexual partner, there is a possibility that you might have got this bug from your partner. This does not necessarily mean that your partner is cheating on you. As I told you earlier, Chlamydia can stay in our body for many months without causing any symptoms. He might have got this infection from his previous relationships.
D: We need to test you both for this infection and treat both of you even if you are positive for Chlamydia.
If pt says cannot bring partner – talk about partner notification programme
D: We need to refer you to Genito-Urinary Medicine (GUM) Clinic.
D: Please bring your son immediately to the hospital if he develops any high fever, drowsiness, neck pain/stiffness, shyness to light, cough, phlegm or breathing difficulty.
Gonorrhoea and Chlamydia are the most common bacterial causes of neonatal conjunctivitis.
Initial Management
- Sticky eye/blocked tear duct: 4-6 hourly eye toilet using sterile saline
- Suspected conjunctivitis:
Swab for: Gram stain and bacterial culture and sensitivities If other suspicions of HSV (e.g. vesicles etc.), viral swab Chlamydia swab (specific for Chlamydia PCR)
Treat with:
- frequent eye toilet as necessary
- chloramphenicol 0.5% eye drops
- Presentation within first 24 hr suggests gonococcal infection
- inform senior paediatrician
● Neisseria gonorrhoeae suspected: Request Gram stain and culture Assess neonate for systemic infection
● Neisseria gonorrhoeae confirmed:
Give single dose ceftriaxone 125 mg IV if IV access present, otherwise IM (40 mg/kg for low- birth-weight babies).
If signs of systemic infection (e.g. sepsis, meningitis), give course of IV ceftriaxone. Refer to ophthalmology.
● Chlamydia result positive:
Treat with azithromycin 20 mg/kg single dose or erythromycin 12.5 mg/kg/dose orally 6 hourly for 2 weeks. This will treat the conjunctivitis and prevent most cases of chlamydia pneumonitis. Monitor for signs of Pyloric stenosis as Macrolides can cause infantile hypertrophic pyloric stenosis when given before 6 weeks.
Gonococcal versus chlamydial conjunctivitis:
| Gonococcal | Chlamydial |
|---|---|
| 2-5 days incubation | 5-14 days incubation |
| Transmission vaginal or from contaminated fingers after birth | Transmission vaginal or from contaminated fingers after birth |
| Mild inflammation with sero-sanguineous discharge | Varies from mild inflammation to severe swelling of eyelids with copious purulent discharge |
| Progression to thick, purulent discharge with tense oedema of eyelids | |
| Complications include corneal ulceration and perforation | Corneas rarely affected |
| Meningitis and sepsis | 1 in 5 untreated will develop chlamydial pneumonitis |
Gonococcal or chlamydia infection detected:
- Refer mother and partner to genito-urinary medicine for immediate treatment Gonococcal versus chlamydial conjunctivitis.