Approach to conjunctivitis in newborns
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-068023 (Published 23 March 2022) Cite this as: BMJ 2022;376:e068023
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Dear Editor
Not many pages before this article was a letter describing how General Practice is still "Bad Mouthed" in hospitals. And here is an article which seems to ignore it altogether.
How realistic is it to refer for immediate assessment numerous babies with conjunctivitis? It may be possible in urban centres, but even then it is likely that worried uncomfortable parents with a newborn will still have to wait some time to be seen. It must be completely impossible in areas of the world where there is little hospital provision, where it is only available at a cost, and also in much of the UK, especially remote and rural areas: such a consultation from here on Islay would require a flight (only 2 per day) or hours on a ferry and then in a car.
As seems to be common, the important ability of GPs to assess risk and treat patients has not been considered. The authors may find that if their advice is followed, they are completely overwhelmed with well babies who need some antibiotic drops: and also with distressed and angry parents.
The advice on how to recognise infectious conjunctivitis was useful, but it would have been really helpful to suggest and update empirical treatment and review. GPs have had extensive training and often years of experience. Can we not be trusted?
Competing interests: No competing interests
Re: Approach to conjunctivitis in newborns
Dear Editor
Manasseh and colleagues’ approach to conjunctivitis in newborns is a welcome reminder of the potential severity of true ophthalmia neonatorum (ON) and the common and usually benign nature of sticky eyes in the newborn. Effective targeted antimicrobial treatment relies on knowing the microbiological cause. The statement that neonatal conjunctivitis remains a clinical diagnosis based on presenting features with laboratory confirmation always a welcome adjunct displays an all to frequent tolerance of poor use of laboratory diagnostics, which if correctly used would identify the vast majority of microbes causing ON.
Empirical topical antibiotics such as chloramphenicol are often ineffective in Chlamydia trachomatis conjunctivitis and fail to prevent subsequent pneumonia. Chlamydia cannot be grown on agar-based media, if specific samples are not taken for nucleic acid amplification tests (typically the polymerase chain reaction) then chlamydia ON will be missed. Diagnosis of chlamydial conjunctivitis is not a useful adjunct but a vital element in the efficient and successful management of ON. Many NAATs combine chlamydia and gonorrhoea improving the yield for gonococcus, whose fastidious growth requirements compromises the sensitivity of conventional culture.
The local use in our laboratory is also sub optimal. A review of ocular samples from neonates demonstrated a common failure to submit suitable samples for chlamydia PCR or in many cases PCR was requested but suitable samples were not sent.
It is likely that many cases of chlamydial ON and subsequent pneumonitis are missed due to inadequate ocular sampling. Locally we append neonatal eye culture results with a request for further chlamydial and gonococcal PCR samples and there is some evidence that this has led to more chlamydia PCR sampling. We must not view diagnostic testing as a welcome adjunct but as a vital step in the diagnosis of this potentially devastating infection and continue to press for better use of the diagnostic laboratory.
Competing interests: No competing interests