Original Article

Conjunctivitis in the newborn- A comparative study

Meenakshi Wadhwani, Pamela D'souza, Rajesh Jain, Renu Dutta1, Arvind Saili2, Abha Singh3
Departments of Ophthalmology, 1Microbiology, 2Pediatrics and 3Gynaecology, Lady Hardinge Medical College, Sucheta Kriplani Hospital, Shahid Bhagat Singh Marg, New Delhi, India
Address for correspondence: Dr. Meenakshi Wadhwani, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, India. E-mail: krgang@rediffmail.com

ABSTRACT Background: Conjunctivitis of the newborn is defined as hyperemia and eye discharge in the neonates and is a common infection occurring in the neonates in the first month of life. In the United States, the incidence of neonatal conjunctivitis ranges from 1-2%, in India, the prevalence is 0.5-33% and varies in the world from 0.9-21% depending on the socioeconomic status. Aim: To study the organisms causing conjunctivitis of the newborn and to correlate the etiology with the mode of delivery. Design: Single center, prospective, observational study. Materials and Methods: A total of 300 mothers and their newborns, born over a period of one year, were included in the study. Of these 200 newborns were delivered through vaginal route (Group A) and 100 (Group B) delivered by lower segment caesarean section (LSCS). At the time of labour, high vaginal swabs were taken from the mothers. Two conjunctival swabs each from both eyes of the newborn were collected at birth and transported to Microbiology department in a candle jar immediately. Results: Eight babies in Group A, developed conjunctivitis at birth. None of the babies in Group B developed conjunctivitis, this difference was statistically highly significant (P<0.000). The organisms found in the conjunctiva of the newborns in Group A were Coagulase negative Staphylococcus , hemolytic Streptococcus, Escherichia coli and Pseudomonas spps. However, the commonest organism leading to conjunctivitis in the newborn in this study was Coagulase negative Staphylococcus. It was observed that the mothers of 5 out of 8 babies (60%) developing conjunctivitis gave history of midwife interference and premature rupture of membranes. So, the presence of risk factors contribute to the occurrence of conjunctivitis in the newborn. Conclusions: It is inferred that the mode of delivery and the presence of risk factors is responsible for conjunctivitis in the newborn. KEY WORDS: Conjunctivitis, lower segment caesarean section, neonate, vaginal delivery

Access this article online Website: www.ijpmonline.org PMID: 21623069 DOI: 10.4103/0377-4929.81584 Quick Response Code:

conjunctival culture consists of mixed flora; Streptococci spps, Corynebacterium and Bacteroides spps are most frequently isolated. It has been observed that though the mother harbours the bacteria or virus capable of causing conjunctivitis in the newborn yet there are no symptoms of infection at the time of delivery.[1,5,8,9]This study was done to detect the organisms causing conjunctivitis in the newborn and to correlate the etiology with the mode of delivery. Ethical clearance was taken from the hospital ethics committee. MATERIALS AND METHODS A total of 300 newborns and their mothers {200 delivered through vaginal route (Group A) and 100 newborns (Group B) by lower segment caesarean section (LSCS)} were included in the study. The inclusion criteria were babies born to mothers with period of gestation 37 weeks without any systemic disease. The criteria for exclusion were, women with intrauterine growth restricted fetus or fetus with gross congenital abnormalities. A detailed antenatal history with a special emphasis on the risk factors like premature rupture of membranes, prolonged labour and unsterile pelvic examination done by

INTRODUCTION Conjunctivitis of the newborn is defined as hyperemia and eye discharge in the neonates and is a common infection occurring in the neonates in the first month of life.[1-4] Different studies have quoted different organisms responsible for conjunctivitis of the newborn. A study done in 1991 by Bezirtzoglou et al,[5] (1993) and Verma et al,[6] (1993) have shown that there are many organisms responsible for conjunctivitis in the newborn, namely Staphylococcus albus spps followed by Enterococcus spps, Escherichia coli, klebsiella and Pseudomonas spps. The present study was carried out to isolate the bacteria responsible for conjunctivitis in the newborn and to ascertain whether the mode of deliverv (vaginal/ caesarean) has any role in the occurrence of conjunctivitis in the newborn . The nature of colonizing organisms is determined by the pattern of the flora in the birth canal and environment.[7] Overall, aerobic organisms are common but most of the
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midwives. Clinical examination of the mothers was conducted and high vaginal swabs were taken at the time of labour from the mother. The study was conducted over a period of one year. Conjunctival swabs were taken from both the eyes of each new born with in 48 hours of birth and transported to microbiology department in a candle jar immediately and subjected to gram stain (to note the presence of epithelial cells and pus cells) and bacterial culture on Blood agar, Chocolate agar and MacConkeys agar (Hi-Media India Private Limited -Mumbai). In case no organism was grown, it was reported as No Growth. If normal flora was grown, it was reported as No pathogenic organism. Any potential pathogen / opportunistic pathogen grown ( hemolytic Streptococci, Staphylococcus aureus, Klebsiella, Escherichia coli spps, Proteus spps) were identified as per standard microbiological techniques and further subjected to antibiotic sensitivity studies. The babies were followed after a period of one month and a repeat conjunctival swab was taken from both the eyes of all newborns. The mothers were advised to report immediately, if their babies developed signs of conjunctivitis in the form of redness and eye discharge. On follow up, a repeat swab was taken from the eyes of these babies which were then further processed for gram stain and bacterial culture and treatment was started. The data was analyzed by chi square tests. OBSERVATION A total of 300 newborns, [200 delivered through vaginal route (Group A) and 100 delivered by lower segment caesarean section (Group B)] with their mothers formed the study group. The study was conducted over a period of one year.
Table 1: Organisms grown in conjunctival swabs in both groups
Conjunctival flora No growth No pathogenic organism Pathogens Coagulase negative Staphylococcus -Hemolytic streptococcus S.aureus Pseudomonas spps Esch Coli spps
P>0.5 (not significant) {chi square test}

Conjunctival swabs from newborns were taken before any medication was instilled in the eye. In Group A 61% of newborns and In Group B 59% showed No Growth. This difference was not statistically significant. No pathogenic organisms were reported in 14% of new borns in Group A and 15% in Group B. The occurance of pathogenic organism in the conjunctiva of Group A and Group B was comparable [Table 1]. The commonest organism grown in the conjunctiva of both the groups was Coagulase negative Staphylococcus spps 20% and 21% in Group A and Group B respectively. [Table 1]. A total of 300 vaginal swabs were examined (200 in group A and 100 in group B) [Table 2]. 10.5% of the vaginal swabs in group A and 1% in group B showed No Growth, whereas 49.5% in Group A and 21% in Group B were reported to grow No pathogenic organism predominantly (normal commensal were Lactobacillus and Gardenella spps). The commonest pathogenic organism in the vagina was Coagulase negative Staphylococcus spps in both the groups, 26.5% in Group A and 33% in Group B respectively. Eight babies in Group A developed signs of conjunctivitis in the form of redness/ discharge in one or both eyes with in 72 hours of birth [Table 3]. Of these 8 babies, 5 had grown pathogens in the conjunctival swabs, where as No growth was reported in the remaining 3 babies. Mothers of these 5 babies were in the age group of 21-25 years and of these 3 were primigravida and 2 were second gravida. All 5 mothers had history of premature rupture of membranes and midwive interference [Table 4]. Of these 5 babies, 4 grew Coagulase negative Staphylococcus spps and 1 grew Staphylococcus aureus spps. Similar organisms were found in the vaginal swabs (Coagulase negative Staphylococcus) of their mothers. All these babies were treated with gentamicin
Table 2: Organisms grown in vaginal swabs in both the groups
Vaginal flora No growth No pathogenic organism Pathogens Coagulase negative Staphylococcus -Hemolytic strep Candida spps S.aureus Esch Coli spps Klebsiella spps
P>0.5 (not significant) {chi square test}

Group A n = 200 % 10.5 49.5 26.5 2 2 8 1.5 21 99 53 4 4 16 3

Group B n = 100 1 21 66 4 1 6 1 % 1 21 33 4 1 6 1

Group A n = 200 122 28 40 1 4 1 4 % 61 14 20 0.5 2 0.5 2 59 15 21 2 1 2

Group B n=100 % 59 15 21 2 1 2

Table 4: Distrbution of mothers of newborns in both the groups according to maternal risk factors
Maternal risk factors History of midwife interference Premature rupture of membranes(>12hrs)
P<0.00 (highly significant) (chi square test)

Table 3: Mode of delivery and conjunctivitis in the new born

Mode of delivery Vaginal delivery Caesarean section Total number of babies 200 100 Conjunctivitis 8 nil

Group A n = 200 37 83 % 18.5 41.5 22 45

Group B n =100 % 22 45

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eye drops and responded to the treatment. This finding suggests the possibility of an early onset of infection derived through the genital tract. The remaining 3 babies where, no growth was reported, developed redness and watering, probably due to non specific inflammation of conjunctiva. None of the babies in Group B showed signs of conjunctivitis. DISCUSSION Conjunctivitis of newborn is prevalent all over the world with a reported incidence varying from 0.9-12% in contrast to India where the incidence is reported from 0.5-33%.[7,10] In this study the percentage of sterile conjunctival cultures were almost equal in both the groups, 61% in Group A and 59% in Group B. Verma et al,[6] (1993), Armstrong et al,[10] and Prentice et al,[11] also had similar results in there study the sterile conjunctival cultures ranged from 44-54%. During pregnancy, it is observed the colonization of the Lactobacillus spps increases in vagina as a result of increased estrogen production. In the present study 49.5% vaginal swabs in Group A and 21% in Group B showed Lactobacillus and Gardenella spps in their cultures. In other studies on pregnant mothers one by Sharon et al,[12] (1991) and another by Goplerud et al,[13] (1976) the vaginal flora showed Lactobacillus spps as the commonest organism. Most of the mother baby pairs in Group A showed Coagulase negative Staphylococcus spps in their vaginal and conjunctival swabs respectively which suggests the possible vaginal route as the cause for the conjunctiva of these babies for acquiring this microorganism while their passage through birth canal. This is similar to findings of Rao K et al,[7](1992), where 85%(68/80) of mother baby pairs (vaginal route) had similar growth.[14] Coagulase negative Staphylococcus spps(21%) were also isolated as the commonest pathogen in conjunctiva of newborns in Group B. Bezirtzoglou et al,[5] (1993) in their retrospective study showed that 13 of the 19 newborns delivered through Caesarean section showed Staphylococcus spps. The possible explanation was the acquisition of these bacteria by repeated vaginal examinations via the nosocomial persons, Malik et al,[15] (2001) in their study on nosocomial infections reported that these occur generally, after a period of 48 hours, Further it was reported that Staphylococcus Epidermidis (Coagulase negative Staphylococcus) were the commonest gram positive organism responsible for these infections. Despite, the use of sterile techniques it is impossible to avoid this mechanism of nosocomial infection for contamination of infant. The most common etiological agent in our study causing conjunctivitis in the newborn were Coagulase negative Staphylococcus spps (60%,5/8). These are similar to the findings of Prentice et al,[11] (21%) and Mohile et al,[2] (2002)
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who also reported staphylococcus epidermidis ( Coagulase negative Staphylococcus) as the commonest organism leading to conjunctivitis in the newborn whereas Verma et al,[6] (35.2%) and Rao k et al,[7] (37.2%) reported Staphylococcus aureus spps as the commonest causative organism in their studies. The commonest organisms in the conjunctival flora in both the groups were Coagulase negative Staphylococcus spps 20% in Group A and 21% Group B respectively. Similar results were reported by Brook et al,[16] (1980) who found that the most common organisms were staphylococcus epidermidis spps (Coagulase negative Staphylococcus) whereas Verma et al,[6] (1993) reported Staphylococcus aureus spps as the commonest organism isolated from the conjunctiva. The occurence of conjunctivitis in the present study is 4 % in contrast to Verma et al,[6]and Prentice et al,[11] who found it to be 7.2% and 8.4% respectively. Three out of eight babies who had conjunctival hyperemia and discharge showed No Growth in their conjunctiva. These 3 babies developed redness probably due to non specific inflammation of the conjunctiva. Risk factors like premature rupture of membranes for more than 12 hours, prolonged labour, history of midwive interference probably contributed to the prevalence of conjunctivitis as 5 out of 8 babies gave history of one or more risk factors. Verma et al,[6](1993) had reported similar findings in their study, this is possible as the infection ascends from vagina to the liqor and ultimately affects the fetus.[17] Four percent babies delivered through vaginal route developed conjunctivitis shows that conjunctivitis in the newborn is uncommon and thus reflects the excellent protocol of maternal and child care in the labour room, operation theatre and nursery leading to a low rate of infection. Thus, the commonest organism isolated from the conjunctival flora of the newborns as well as genital tract of the mothers in Group A were Coagulase negative Staphylococcus. Conjunctivitis in the newborn was observed only in the newborns delivered by the vaginal delivery (P<0.01 ) (chi square test). CONCLUSIONS Though the sample size is small for significant statistical conclusions but it is inferred that the mode of delivery and the presence of maternal risk factors may have a causal relationship with the occurrence of conjunctivitis in the newborn. REFERENCES
1. Ohara MA. Ophthalmia neonatorum. Pediatr Clin North Am 1993;40:715-25.

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Wadhwani et al.: Conjunctivitis in newborn 2. Mohile M, Deorari KA, Satpathy G, Sharma A, Singh M. Microbiological study of neonatal conjunctivitis with special reference to chlamydia trachomatis. Indian J Ophthal 2002;50:295-9. 3. Duke elder S. System of ophthalmology (Conjunctiva). Inflammation of the conjunctiva and associated inflammation of the cornea in disease of the outer eye. Vol. 8. London: Henry Kimpton; 1965. p. 115-23. 4. World Health Organization. Conjunctivitis of the newborn: Prevention and treatment at primary health care level. Geneva: WHO; 1986. 5. Bezirtzoglou E, Romond C. Nosocomial infections of ocular conjunctiva in newborns delivered by caesarean section. Ophthalmic Res 1993;23:79-83. 6. Verma M, Chhatwal J, Varughese PV. Neonatal Conjunctivitis: A profile. Indian Pediatr 1994;31:1357-61. 7. Rao K, Ramji S, Thirupuram S, Prakash K. Clinical and bacteriological study of normal and inflamed neonatal conjunctivae. Indian Pediatr 1992;29:161-5. 8. Isenberg SJ, Apt L, Yoshimori R, McCarty JW, Alvarez SR. Source of the Conjunctival bacterial flora at birth and implications for ophthalmia Neonatorum Prophylaxis. Am J Ophthalmol 1988;106:458-62. 9. Pierce JM, Ward ME, Seal DV. Ophthalmia neonatorum in the 1980s: Incidence, aetiology and treatment. Br J Ophthalmol 1982;66:728-31. 10. Armstrong JH, Zacharias F, Rein HF. Ophthalmia Neonatorum A chart review. Pediatric 1967;57:884-92. 11. Prentice MJ, Hutchinson GR, Taylor-Robinson D. A microbiological study of neonatal conjunctivae and conjunctivitis. Br J Ophthalmol 1977;61:601-7. 12. Hillier SL, Krohn MA, Nugent RP, Gibbs RS. Characteristics of three vaginal flora patterns assessed by gram stain among pregnant women: Vaginal infections and prematurity study group. Am J Obstet Gynecol 1992;166:938-44. 13. Goplerud CP, Ohm MJ, Galask RP. Aerobic and anaerobic flora of the cervix during pregnancy and Puerperium. Am J Obstet Gynecol 1976;126:858-65. 14. Etches PC, Leachy F, Harris D, Baum JD. Lysozyme in the tear of newborn babies. Arch Dis Child 1979;54:218-21. 15. Malik A, Hasani SE, Khan HM, Ahmad AJ. Nosocomial infections in the newborns. Indian Pediatr 2001;38:68-71. 16. Brook I, Barrett CT, Brinkman CR, Martin WJ, Finegold SM. Aerobic and anerobic bacterial flora of the maternal cervix and new born gastric fluid and conjunctiva: A prospective study. Pediatrics 1979;63:451-5. 17. Udani RH, Vaze S, Reys M, Paul SS. Premature rupture of amniotic membranes and neonatal infection: Predictive value of bacteriologic culture from different sites. Indian J Pediatr 1980;47:137-40.
Source of Support: Nil, Conflict of Interest: None declared.

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