Practitioner Care and Screening Guidelines for Infants Born to Chlamydia-Positive Mothers

Debbie M. Popovich, MSN, RN, CPNP; Allison McAlhany, MSN, RN, CPNP

NAINR. 2004;4(1) 

In This Article

Clinical Presentations and Treatment

Conjunctivitis has a variety of presentations in the neonate. Chlamydial infection is the most common cause of neonatal conjunctivitis, usually appearing between day 5 and day 12 of life.[2] Unlike gonococcal conjunctivitis that is purulent, chlamydial conjunctivitis usually presents with watery discharge. It is difficult to differentiate the cause of conjunctivitis in the neonate because the differential diagnoses may include chemical irritation from prophylactic agents used in the hospital (which will often resolve spontaneously within a few days), nasal lacrimal duct obstruction, viruses, and bacteria. To accurately diagnose the many etiologies of conjunctivitis, a culture of the conjunctival cells with exudate is required. The neonate's eyelid is everted and a specimen is obtained using the appropriate manufacturer's swab.[2] While awaiting culture results, it is reasonable to treat the neonate prophylactically with erythromycin ophthalmic ointment. If the culture is positive for C. trachomatis, oral therapy is indicated. Erythromycin ethylsuccinate 50 mg/kg/d orally divided into four daily doses for 14 days is the current CDC recommendation; however, practitioners must be aware that erythromycin estolate is contraindicated in liver disease.

Once the chlamydia organism spreads from the conjunctiva to the lacrimal ducts and the nasopharynx, 33% or more of infants will develop chlamydial pneumonia.[3] In the event conjunctivitis does not occur, 11 to 20% of infants born to chlamydia-positive untreated mothers will develop chlamydial pneumonia. Symptoms of chlamydial pneumonia are a repetitive staccato cough, tachypnea, and hyperinflation and bilateral diffuse infiltrates on chest x-ray (CXR). Chlamydial pneumonia should be treated with oral erythromycin; however, given the antibiotic treatment failure rate of 20%, repeated cultures and CXRs may be required in symptomatic infants. Left untreated, the disease has a protracted course lasting weeks to months. A long-term follow-up study of children who had C. trachomatis pneumonia in the first six months of life demonstrated that these children had a higher than normal frequency of reactive airway disease.[6]

Although erythromycin is the treatment of choice for neonatal chlamydial infections, health care providers must also assess for its potential adverse effects. Numerous studies have shown an association between erythromycin and infantile hypertrophic pyloric stenosis (IHPS). In a 2002 Vanderbilt study, Cooper and coworkers[7] reviewed charts of 804 infants, 3 to 90 days old, and found an almost eightfold increase in IHPS in those infants who were exposed to erythromycin between 3 and 13 days of age. Mahon and coworker's[8] study also confirmed a correlation between infants treated with systemic erythromycin and subsequent IHPS, finding the highest risk to be within the first two weeks of life. There was no association found in infants treated with erythromycin ophthalmic ointment. Erythromycin's widely known gastrokinetic properties have been suggested as the mechanism that causes this phenomenon.[9] The risk of other macrolides, such as azithromycin dihydrate and clarithromycin, causing IHPS is unknown. Although a 1998 study by Hammerschlag and coworkers found oral azithromycin to be an effective alternative to erythromycin in either 20 mg/kg as a single dose or 20 mg/kg once daily for three days, the AAP continues to recommend erythromycin for treatment of diseases caused by C. trachomatis.[10] In the infant's plan of care, health care providers must include a comprehensive assessment for the potential adverse effect of IHPS along with guidance for parents. Although erythromycin is known to cross the placenta, a 2002 study by Louik and coworkers[11] of infected mothers treated with erythromycin during pregnancy found no evidence of increased risk of pyloric stenosis in their infants.

For infants who do not tolerate erythromycin, Garrity[12] suggests that oral sulfonamides be given as an alternative after the immediate newborn period. However, providers must be cautious and scrupulous in educating parents on the risks of this treatment and in assessing for the potential sequelae of sulfonamides, which include erythema multiforme (EM), Stevens-Johnson syndrome (SJS), or toxic epidermal necrolysis (TEN). A 10-year review of 61 pediatric patients with a diagnosis of EM, SJS, or TEN by Forman and coworkers[13] identified sulfonamides as one of the etiologic agents in 26% of the children.

To conclude the case presentation, the 1-week-old infant was found to have C. trachomatis by culture and was subsequently placed on erythromycin at the recommended dosage for 14 days. His CXR was negative and he remained afebrile and without respiratory signs. The conjunctivitis cleared within three days of antibiotic initiation and remained clear thereafter.

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