Epidemiological Study of Neonatal Conjunctivitis

Imam Hossein , Resalat and Shahid Akbar Abadi Medical Centers
School of Medicine, Shahid Beheshti University
Tehran, Iran / 2001-2002

Authors:

M.H. Soltanzadeh, MD; Professor of Pediatrics, Imam Hossein Medical Center
Jaleh Rajavi, MD; Professor of Ophthalmology, Imam Hossein Medical Center
Afshin Behzadifar, MD; Resident of Pediatrics, Imam Hossein Medical Center
Amir Hoshangh Arbabi, MD; Assistant Professor of Pediatrics, Shahid Akbar Abadi Medical Center.
Naser Badami, Ph.D.; Associated Professor of Microbiology, School of Medicine. Tehran University.
Maliehe Khodami, MD; Assistant Professor of Pathology; Imam Hossein Medical Center
Fatemeh Ashrafi, PHD; Clinical Laboratory

Abstract

Objective: To study the epidemiological characteristics of Bacterial Neonatal Conjunctivitis in three hospitals (Imam Hossein, Resalat and Shaid Akbar Abadi) from 2001 to 2002.

Methods and Materials: This descriptive study was conducted on all 3140 neonates, who were born in obstetrics and gynecological wards, from January 2001 to September 2002, in the aforementioned hospitals, after obtaining written consent from their mothers.

At first, the questioner was filled up by asking the mother and referring to hospital documents, then in the cases with signs of conjunctivitis, sample was taken by sterile swab from inferior cul de` sac and conjunctival discharges, and direct smears, Gram and Geimsa staining and culturing on blood agar, chocolate agar and thioglicolate , was  performed at the bed  of the neonate.

Another sample for Chlamydial study was taken for direct immunofluorescent (DIF), and was fixed by acetone.
This latter sample was sent to Health Faculty of Tehran for further evaluations by immunofluorescent microscope. At the time of discharge, all mothers were mentioned to return their neonates to pediatric clinic, if any abnormal eye presentations were seen.

Each week, by calling up, necessary information were taken from all mothers and they were invited for revisiting as needed. Data were analyzed by descriptive statistics of SPSS software.

Results: Of 3140 neonates, who were studied, 2500 (76.6 %) were from Shahid Akbar Abadi, 340 (10.8 %) from Imam hossein l and 300 (9.6 %) from Resalat hospitals.

_ 1699 (54.1 %) were male and 1441 (45.9 %) were female.

_ 170 of 3140 neonates had signs of conjunctivitis (prevalence 5.4%). 

_ 82 out of 170 cultures (48%) were negative. From positive cultures 26 (15%) were Coagulase negative staphylococcus, 23 (13.5%) Staphylococcus epidermis, 13(8%) E.coli and 10(6%) were Staphylococcus aureus and other microorganisms had low percentages.

_From 170 samples for Chlamydia, 10(6%) were positive, 6 of them were also culture positive for bacteria and 4 were isolated DIF positive.

Conclusion: Prevalence of Neonatal Conjunctivitis has been reported to be 1.64% to 66.5%. Prevalence of 5% in this study shows an acceptable result. Gram Positive Cocci were the most common cause of bacterial infections.

Bacterial cultures were negative in 48% of neonates despite positive signs of conjunctivitis.

Lower rate of Chlamydial Neonatal Conjunctivitis in this study as compared to other reports in Western countries may be due to lower prevalence of sexually transmitting infections in Iran.

Keywords: Bacterial infections, Neonatal Conjunctivitis, Chlamydia.

Introduction:

Ophthalmology Neonatorum is one of the most common infections during  the  first  month  of  life  and  its  prevalence  has  been reported to be  between 1.6-66.5%^(1-4).

Clinical signs include redness, tearing, secretion, conjunctiva and  palpebral  inflammation a pseudomembrane and corneal  perforation. Its complications are corneal involvement ,  perforation and  blindness. Silver nitrate is a cause of mild conjuctivitis that is self-limited.

Bacterial agents that has been reported as causes of neonatal conjunctivitis are staphylococcus aureus, hemophillus influenzae , staphylococcus pneuomonia, gonococcus,pseudomonas aureogenosa and chlamydia trachomatis², which the prevelances are variable in different societies due to their different cultures, economies and health factors.

For example nowadays chlamydia trachomatis is one of the most common causes of neonatal conjunctivitis in Western communities. Different lab tests are used to detect clamydia trachomatis, such as, DEFA⁴, directimmunofluroscent (DIF)⁵, Elisa⁶, PCR (Polymorase Chain reaction) and Giemsa staining .

Table No 1: Frequency distribution of absolute and relative of conjunctival discharge smears in neonatal conjunctivitis / Shaheed Akbar Abadi , Resalat and Imam Hossien centers / 2001-2

 N=number

The maternal and neonatal precipitating factors increase conjunctivitis³.

Considering, different prevalances and risk factors of conjunctivitis in different societies, this study has conducted in three medical centers( Imam Hossien , Resalat and Shaheed Akbar-Abadi centers) to  determine  the  prevalence of   bacteril    and chlamydial causes of neonatal conjunctivitis in our community, as long as epidomiological recognition of neonatal conjunctivitis in our community may be greatly helpful in  prophylactic and timely remedial programs.

Methods and materials: This descripitve study has been conducted on  3140,  born from 22.12.2001 to 22.7.2002 in three medical centers  Imam Hossien , Rasalat and Shaheed Akbar Abadi, after obtaining informed consent from their parents.

Neccessary questions about education, gestational age, pariety , prenatal care , route of delivery, prematune rupure of amniotic membranes and urinary tract infections, have been asked and filled in by pediatric resident questainere. Then necessary data about neonate such as date of birth , gestational age , weight , gender , first and fifth minute apgars , prematuriy history , Sepsis , Pulmonary and Skin infecion , hospitalsation duration have entered from their files and filled in the questaineres.

The necnatal eyes has inspected by pediatric resident and if it  was any sign of conjunctivitis (redness , inflammation, watery or purulent discharge , epiphora , hemorrhage , pseudomembrane , Corneal opacity and corneal perforation) the neonate refered To ophthalmology clinic for more mispections and then their signs , time of occuring from birth , Right or left or both eye (s) involement was recorded.

The Samples have taken from inferior cul de sac with sterile Swabs and they were stained with gram and Giemsa Stained by laboratory technicians.

The Samples were cultured on aerobical medias such as blood agars , chocolate agar and Thioglycolate media and the samples has sent to Imam Hossien hospital laboratory.

For Chlamydia Study after preparing direct immunofluorescent slides and fixing them with acetone, the samples sent to Tehran health faculty for evulation with immunofluorescen microscope by our colleague and the results have recordad.

During discharging of neonate from hospital , we noticed the mother that if she has seen any conjunctivitis signs in neonate up to one month age Come back to pediatric clinic for more evaluation and treament and if the parents have not had any contact with us, we have done it .

We called the parents every weeks by phone and asked them about  their neonates eyes and if there was any signs we invited the parents and their neonates for evaluation and if the parents didn’t come , a trained nurse has gone to their homes for getting information and sending the neonate to hospital for treatment.

The results have analysed with descriptive statistics.

Table No 2: Frequency distribution of absolute and relative of Direct immunofluroscent results in neonatal conjunctivitis / Shaheed Akbar Abadi , Resalat and Imam Hossien centers / 2001-2

N=number

Results:

This study has done on 3140 neonates that 2500 of them were from shahid Akbar Abadi center (80%) and 340 neontes from Imam Hossien Center (11%) and 300 neonates from Resalat center (9%).

1699 neonates were male (54%) and 1441 were fomale (46%).

In 170 neonates one or more conjunctivitis signs have seen , its prevalence was 54% , single eye involvement was in 70.5 % and both eyes in 27.5 % of patients have seen.

The results of smears and bacterial cultures and DIF for Chamydia have showed in tables 1 and 2 and Chart 1 .

The most organism in smears was Cocci gram positive in 20.5 % and in aerobic culture it was Cocoi gram negative in 15 % of cultures.

Chalmydia has seen in 6% of DIF Samples and we had 48% negative culture resulrs in spite of positive Conjunctivitis signs.

The most common risk factor in mothers  was PROM (Prolonged ruptune of membrane) that was found in 17 cases (10%). The 37% of mothers were primigravid and 39% second gravidity and 39% have third or more tham three gravidity.

Pregnancy in age less than 15 y/o was only in 1.8% of mothers.

-  88% of mothers had prenatal care (PNC) and 25% had delivered by   cesarean section.     

The most Common risk factor in neonatal Conjuntivitis was their gender that it was more in mals than females () and the other risk factors are mentioned in table 3.

As mentioned in Chart 2 , the most Common neonatal Cojunctivitis signs in order of decrement were eye secretion in 92% and redness in 73.5% of cases and the pseudomembrane was in the least of cases (2%).

          Certainly the most of signs were seen together.

The beginning of neonatal Conjunctivitis in 30 days follow up was 3.7 6.4 days. (table No 3) .

Discussion:

In our Study 170 (5.4%)  of neonates have conjunctivitis signs that the most microbial organisms in order of decrement were S. Coagulase negative (15.3%) , S. epideimis (13.5%) , E. coli (7.6%) ,5.4% of cases were DIF Positive and 48.2% of them had negative microbial culture results. (tables No 1,2 and Chart No 1)

In study that Dr Iroha Eo and his Colleagues has done in Laues in 1998 on 150 hospitalised neonates , the prevalence of conjuntivitis was reported 1.8% that their microbial causes in increment order were S.auerus (37.4%) , Klebsiella Pneuomonia (12.9%) , S. Coagulase negative (12.3%) .

The cause of lesser of prevalence in this study can be due To lesser samples or due to study of only hospitalized patients that the researchers had found lesser positive cases. Staphylococcus coagulase negative prevalence in our both studies was as same , but differences in other microcorganisms prevalences Can be due to differences in infections between two societies ,also in this Study the number of negative cultures have not indicated .

In Study that Dr lise Dannevig and his Colleagues have done in 1928 neonates in north Norway in 1985-1986 with a 6 weeks follow up , they reported that the prevalence of neonatal conjunctivitis is about 19% and Prevalence of Chlamydial infection was about 5.95% between them.

The cause of high prevalence in this research can be due to use of new and better lab methods with high sensitivity in their study or can be due to more longer follow up (6 weeks instead of 4 weeks in our study).

The prevalence of chlamydial involvement in our both studies was as same.

In study that Dr Mani R has done on 86 neonates between years 1991 and 1993 in a hospital in Kalhamangalan , the prevalence of neonatal Conjunctivitis has reported about 36% that the bacterial causes in incremental order were Piocyanic (50%) , S. aureus (20%) , Pneumococcus (10%) and H. influenza (6.5%)³ . The high conjunctivitis prevalence in this study can be due to high risk mothers or neonates in this society.

Also differences in growth bacteria that have been reported in this study can be due to low hygiene in that society.

The number of samples in this study was less than us (86 instead of 3140 in our study) can intererven in the microorganisms prevalence.

In study that Dr Pantey K has done in India on 245 neonates between years 1986-1988 , about 163 of them (66.5%) has positive cultures that 12% of them were Staph Coagulase negative¹⁰. The high prevalence in this study has showed that in India , there are more infection in mothers and neonates than our society .

In Study that Dr Salpietro has done on 180 neonates with Conjuntivitis Signs , the prevalence of chlamy dia was about 41%¹¹.

The high Chlamydial infection in this study in comprison of ours (41% in comprison of 5.89%) can be due to High Sexual transmitted disease (STD) in West Countries , because Sexual transmitted is the most important route of Chlamydial Conjunctivitis infection.

In our study from 170 neonates with conjunctivitis signs , there were 62.4% males and 37.6% females that their proportion was 1.66 To 1. (table No 3)

- In Dr Lise Dannevig study on 1928 neonates in North Norway , 75% of neonates with conjunctivitis were male and 25% females⁹.

In Dr Vishut Bhat study on 245 neonates the proportion of conjunctivitis between males To females was 1.1 to 1¹⁰.  In Dr H.Nsanze study on 81 neonates in Saudi Arabia in Neonatal Intensive Care Unit , 63% of neonates with conjunctivitis were males and 37% females¹².

As the results Show in these three studies , in the all, the affected males were more and may be gender is a important risk factor in neonatal conjunctivitis.

Table No 3: Frequency distribution of absolute and relative risk factors of neonatal conjunctivitis Shaheed Akbar Abadi , Resalat and Imam Hossien centers / 2001-2

N=number

In our study right, left and both eye(s) Conjunctivitis  were 36.5% , 44% and 26.5% respectively (table 3), that these results are Same as Dr H.Nsan 30 Study⁷. In our study the onset of conjunctivitis signs in a 30 days follow up were 3.7 6.4 days. (table No 3)

In Dr Vishut Bhat`s study on 245 neonates in 10 days follow up, the onset of conjunctivitis have been reported about 42 days. These two studies has showed same median for conjunctivitis onset but in our study the range was higher , and its cause can be due to longer study duration.

In our study the 75% of neonates have born vaginally and 65% of them with C/S.

The study that Dr Fariba Shirvani and Dr Mohammad Sharifi have done in Tehran on 49 neonates with conjunctivitis in 1998 , 40.8% of them have born vaginally and 59.2% of them with C/S¹³ .

This difference can be due to maternal delivering choice that nowadays the rate of cesarean has came upper and this cannot related To neonatal conjunctivitis.

In our study the average of neonatal weight was 3062  639.4 in age range of 0 To 5 days with mode of 2 days (table 3).

In Dr Fariba Shirvani Study on 49 neonates with canjunctivitis the average weight was 2979 667  g in age range of 0 To 6 days¹³.

In Dr Nsanzo study in Saudia Arabia on 81 hospitatized neonates in Neonatal Intensive Care Unit (NICU) , they reported that the average of neonatal weight was 2852 grams¹² . 

The results of Dr Shirvani Study have more Similarity to ours and may be in Dr Nsanzo study due to NICU admission the neonates have lower weights and the cause of it, is their disease.

In our study maternal iliteracy was 16.5% and Premature rupture of membrane was 10% of cases that there two were the imporant maternal risk factors .

In Dr Iroha Eo study on 150 neonates with neonatal conjunctivitis , vaginal delivery , asphyxia , PROM were the important risk factors⁸.

In case PROM was the important risk factor in both studies.

Conclusions:

Mentioning Variable prevalences of conjunctivitis in differ societies from 1.6% To 66.5% , it seems necessary more studies with more cases To be done.

However our study shows a reasonable prevalence of conjunitivitis among other societies.

Prevalence of microbial causes are different among different Societies , but Coagulase negative Staphylococcus and E. coli and Piocianic are among the most important ones. (chart 1)

Prevalence of chamydial conjunctivitis in our society is 6% and it is lower than western conuntries because of lower STD (sexual transmitted diseases) prevalence in our society. (Table No. 6)

Conjunctivitis is more prevalence among males than females based on our results (64.4% and 37.6% respectively). (table No. 3)

Mean age of conjunctivitis occurrence is the 3^rd to 4^th days of birth (table No. 3)

Prolonged rupture of amnioric membranes are among the important risk factors for neonatal conjunctivitis occurrence.

Unlilateral conjunctivitis is more than bilataral (70% in our study)

In spite of conjunctivitis signs , half of the patients have negative microbial culture (chart 1) .

References:

1. McMillan A J, DeAngelis D C, Feigin D R, Warshaw B D. “ Oski`s pediatrics ” , 3 rd ed, Lippincot`s Williams and Wilkins, USA,1999; 668-670

2. Dunn MP. Dr Cal Crede (1819-1892) and the preventation of ophthalmia neonatrum. ARCH DIS FEAL NEONATRUM ED , 2000;83,158-159.

3. Mani VR. A microbiological study of ophthalmia neonatrum in hospital-born babies . J INDIAN MED ASSOC, 1997;95(7):416-417

4. Zhang W, Wu Y Zhao J. Rapid diagnosis and treatment of chlamydial conjunctivitis. CHIN MED J, 1995; 108(2):138-139.

5. Taylor HR , Fitch CP, Murillo_ Lopez F, Rapoza P.  The diagnosis and treatment of chlamidial conjunctivitis. INT OPHTHALMOL, 1998; 12(2):95-9.

6. Abdel Rahman MM,  Abdel Dayem SI, Eid SA, Badie OA, Kotb NA.Immunofluorescent diagnosis of chlamidia trachomatis infection of the respiratory tract and the eye. J EGYPT SOC PARASITOL, 1993; 23(3): 659-65.

7. Baveja UK, Hiranandani MK,Talwar P, Sen DK. Laboratory techniques for diagnosis of chlamidial infections of the eyes. J COMMUN DIS. 1997;29(3) : 247-53.

8. Iroha EO, Kesah CN.Bacterial eye infection in neonates a prospective study in a neonatal unit .WEST AFR J MED , 1998;17(3) :168-172.

9. Dannevig  L, Straume B, Melby K.Ophthalmia neonatrum in Northern Norway. ACTA OPHTHALMOL, 1992,70:14-18.

10. Pandey  KK,Vishu Bhat B, Kanungo R, Srinivasan S,Sambasive Rao . Clino-Bacteriological study of Neonatal conjunctivitis. INDIAN J PEDIATR , 1990;57: 527-531.

11. Salpietro CD, Bisignano G, Fulia F, Marino A, Barberi I. Chlamidia trachomatis conjunctivitis in new borne. ARCH PEDIATR. 1999 ; 6(3) : 317-20 .

12. Nsanze H, Dawoud A, Usmani A, Sabarinathan K, Varady E.Ophthalmia neonatrum in the Unitd Arab Emirate. Ann Trop Paeditr, 1996; 16(1) : 27-32.

13.Shirvani F, Sharifi M, Affected factors in Ophthalmia neonatrum in neonates born in Boali hopital in Tehran / second trimester  1998.  Residency Theses

Home page  | Introduction |  Research Studies  |  Editorships  |  Translations  |  Conferences 

Contact Information  |  Articles  |  Scientific meets & events  |  Research projects  |  Theses