Keeping an Eye on Chlamydia and Gonorrhea Conjunctivitis in Infants in the United States, 2010–2015

To the Editor: We read with interest the analysis conducted by Kreisel et al.,1 who examined the national rates of reported neonatal conjunctivitis due to Chlamydia trachomatis and Neisseria gonorrhoeae in the United States. The emphasis was concern over the efficacy of neonatal ocular prophylaxis, as erythromycin is the only available preparation available in the United States.2 Neonatal ocular prophylaxis with silver nitrate, topical erythromycin, or tetracycline ointment, although effective for prevention of gonococcal ophthalmia, does not prevent chlamydial ophthalmia or nasopharyngeal colonization with C trachomatis or chlamydial pneumonia.2–4 Prospective studies of mother-to-infant transmission of C trachomatis conducted in the 1970s and 1980s suggested that neonatal ocular prophylaxis with silver nitrate did not prevent chlamydial conjunctivitis, nasopharyngeal infection, or pneumonia,4 as silver nitrate was routinely used for neonatal ocular prophylaxis at the time of those studies. Hammerschlag et al.3 screened 4357 pregnant women for C trachomatis infection; 341 (8%) were positive. Their infants were randomized to receive 1% silver nitrate, erythromycin, or tetracycline ophthalmic ointments at birth; 230 infants were followed up for 3 months for conjunctivitis, nasopharyngeal infection, and/or chlamydia pneumonia. The incidence of chlamydial conjunctivitis in these infants was 20%, 14%, and 11%, respectively (P > 0.25). There were also no differences in the incidence of nasopharyngeal infection (in infants with conjunctivitis and asymptomatic infection) or subsequent development of chlamydia pneumonia. Prenatal screening and treatment of pregnant women is the most effective way of preventing perinatal chlamydial infection, as demonstrated for gonococcal infection and syphilis. Implementation of prenatal screening and treatment in the 1990s has resulted in a dramatic decrease in neonatal chlamydial conjunctivitis and pneumonia in our population in Brooklyn, NY. For example, before implementation of prenatal screening, we saw approximately 30 to 40 cases of chlamydial conjunctivitis/year. Last year, we saw our first case in almost 20 years. The mother was screened and treated but was reinfected by her untreated partner late in pregnancy. Cases will still occur, but not in the numbers we used to see. In 2015, the Canadian Pediatric Society recommended that neonatal ocular prophylaxis be discontinued in Canada and be replaced by enhanced prenatal screening for C trachomatis and treatment for pregnant women.5 The program began implementation in 2016. If there is exposure to gonorrhea, the infant should receive ceftriaxone intramuscularly.4 The Centers for Disease Control and Prevention makes the same recommendations regarding newborn infants exposed to gonorrhea even if they have received neonatal prophylaxis.2 A seroepidemiologic study of C trachomatis infection in children in our population provides indirect evidence that prenatal screening and treatment has greatly reduced perinatal chlamydial infection.6 Prevalence of antibody in infants younger than 1 year reflects rates of maternal infection; this antibody disappears at 1 year of age and does not reappear until 11 to 12 years of age with the onset of sexual activity. In contrast, in sera collected from children before the implementation of prenatal screening and treatment, the chlamydia antibody persists to 5 to 10 years of age.6 Crede7 proposed the use of silver nitrate for prevention of gonococcal ophthalmia in 1881. It goes without saying that much has changed over the intervening 136 years, including the discovery of C trachomatis and the development of antibiotics. Neonatal ocular prophylaxis is currently outdated and unnecessary in the United States. Margaret R. Hammerschlag, MDTamar Smith-Norowitz, PhDStephan A. Kohlhoff, MD Department of Pediatrics Division of Infectious Diseases SUNY Downstate Medical Center Brooklyn, NY

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