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Asian Pac J Trop Dis 2013; 3(6): 429-433

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Asian Pac J Trop Dis 2013; 3(6): 429-433 429 Contents lists available at ScienceDirect Asian Pacific

Contents lists available at ScienceDirect

Asian Pacific Journal of Tropical Disease

journal homepage: www.elsevier.com/locate/apjtd

Asian Pac J Trop Dis 2013; 3(6): 429-433 429 Contents lists available at ScienceDirect Asian Pacific
 

Document heading

doi: 10.1016/S2222-1808(13)60096-1

2013 by the Asian Pacific Journal of Tropical Disease. All rights reserved.

A microbiological study of neonatal conjunctivitis in two hospitals in Tehran, Iran

Seyed Abolfazl Afjeiee 1 , Sedigheh Rafiei Tabatabaei 2 * , Fatemeh Fallah 2 , Farideh Shiva 2 , Nafiseh Tahami Zanjani 2 , Arezou Tavakkoly Fard 2 , Saadat Adabian 2 , Mohammad Rahbar 3,4 , Ramin Nourinia 5 , Abdollah Karimi 2

1 Department of Neonatal Disease, Mahdieh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 Department of Microbiology, Reference Health Laboratories Research Center, Ministry of Health & Medical Education, Tehran, Iran 4 Antimicrobial Resistance Research Center, Tehran University of Medical Sciences, Tehran, Iran 5 Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran Iran

PEER REVIEW

ABSTRACT

Peer reviewer

Objective: To determine the prevalence of neonatal conjunctivitis and to identify the causative

  • D V a n a j a

r .

K u m a r ,

H e a d

o f

t h e

agents of ophthalmia neonatorum in two university affiliated hospitals from 2008 to 2009.

o f

  • D Methods: All n e o n a t e s a dmitt e d i n t h e n e o n a t a l d e p a rtme n t d u ri n g t h e st u d y p e ri o d we r e examined for the presence of conjunctivitis. Two swab specimens containing epithelial cells of the

e p a r t m e n t ,

D e p a r t m e n t

B a c t e r i o l o g y , N a t i o n a l I n s t i t u t e f o r

R e s e a r c h i n T u b e r c u l o s i s , C h e t p e t ,

Tel: +91-044-28369659

E-mail: Vanaja_kumar51@yahoo.com

Comments

This is a good study which reveals the

Chennai-31, India.

conjunctiva were collected from newborns presenting with conjuntival inflammation. Laboratory

diagnosis was based on direct smear for Gramstaining and bacterial culture. The isolated bacteria

were identified using standard procedures. PCR and cell culture were used for identification.

Results: Of the 2 253 neonates, (age ranged 1-30 days), clinical findings of conjunctivitis were f o u n d i n 2 4 1 c a s e s ( 1 0 . 7 % ) . T h e m o st c o m m o n l y is o l a t e d b a c t e ri a w e re Coagulase negative

incidence of the neonatal conjunctivitis in both hospitals. Bacterial etiologic a g e n t s w e r e d i s c u s s e d . T h e a u t h o r s h a v e s c r e e n e d t h e e t i o l o g i c a g e n t s o f ne ona t a l c onjunc ti v itis fr om the ir

staphylococci, (n=130, 53.9 % ); Chlamydia trachomatis was the second most common cause of acute neonatal conjunctivitis (n=40, 16.6 % ). Bacterial cultures were negative in 47 neonates (19.5 % ) despite clinical signs of conjunctivitis. The median age at presentation for bacterial culture positive was day 8 of life. Conclusions: N e o n a t a l c o n j u n c t i v i t i s i s p r e v a l e n t i n n e w b o r n s ; G r a m p o s i t i v e c o c c i a n d Chlamydia trachomatis are the most common causative organisms.

g e o g r a p h i c a l r e g i o n s . T h e a r t i c l e c r e a t e s si g n i f i c a n t o u t c o m e t o w a r d s the treatment.

KEYWORDS

Details on Page 432

Neonate, Bacterial conjunctivitis, Chlamydia trachomatis

1. Introduction

Neonatal conjunctivitis (ophthalmia neonatorum), is a commonly encountered problem which presents during the first month of life [1] . The causes can be septic (bacterial or viral) or aseptic (e.g. a chemical agent such as topical silver nitrate) and the majority of infectious neonatal conjunctivitis a re o f ba c t e ri a l e ti o l o g y [2,3] . In spit e mo st o f the se c a se s a r e b e n i g n , s o m e o f t h e m m a y p r o g r e s s t o s y s t e m i c

complications or visual loss if left untreated. Often, but not invariably, bacterial conjunctivitis has a longer incubation p e ri od a s c omp a r ed t o o th e r in f e c ti v e c au s e s [4] . Clin i c a l signs include redness, tearing, secretion, conjunctival and palpebral inflammation, a pseudomembrane and corneal perforation which may result in blindness [5] . The most commonly etiology agents of conjunctivitis are Gram-positive organisms include Staphylococcus aureus (S. aureus ), Streptococcus pneumoniae, Streptococcus viridans,

*Corresponding author: Sedigheh Rafiei Tabatabaei, Pediatric Infections Research Ce n t e r, Mo f i d Ch i l d r e n Ho s p i t a l , S h a h i d Be h e s h t i Un i v e rsi t y o f Me d i c a l S c i e n c e s, Tehran, Iran.

Tel: 00982122226941

E-mail: rahbar_reflab@yahoo.com Foundation Project: Supported by the Pediatric Infections Research Center, Tehran, Iran.

Article history:

Received 3 Aug 2013 Received in revised form 9 Aug, 2nd revised form 13 Aug , 3rd revised form 17 Aug 2013 Accepted 28 Oct 2013 Available online 28 Dec 2013

  • 430 Seyed Abolfazl Afjeiee et al./Asian Pac J Trop Dis 2013; 3(6): 429-433

a n d Staphylococcus epidermidis ( S. epidermidis ) ; G r a m - n e g a t i v e o r g a n i s m s , s u c h a s Escherichia coli , Klebsiella pneumoniae, Serratia marcescens, Proteus, Enterobacter, and Pseudomonas species, also have been implicated [5] . These later organisms are probably acquired after birth, as their mod e o f d e li v e r y h a s littl e in flu en c e on th e in c id en c e [6] . Chlamydia trachomatis ( C. trachomatis ) a n d N e i s s e r i a gonorrhoea (N. gonorrhoea) are the two well described agents associated with ophthalmia neonatorum, and are known to be associated with systemic complications and severe visual loss [7-9] . High-quality antenatal care in the West and the use of i n t r a p a r t u m a n t i b i o t i c s t o t r e a t a p o s i t i v e h i g h - v a g i n a l swab has led to a dramatic reduction in the incidence of gonococcal conjunctivitis [3] . Topical eye drops such as silver nitrate effectively prevent gonococcal neonatal conjunctivitis but it is not effective against chlamydial conjunctivitis. The exact cause of neonatal conjunctivitis cannot generally be identified on clinical grounds alone. The timing of symptom onset and a history of maternal sexually transmitted disease ma y g i v e s ome c l u e s t o t h e u n d e rl y i n g c a u s e b u t d o n o t provide a definite diagnosis [10] . In England, in the mid-1800s, there was a hospital devoted solely to the lavage of infants with gonococcal ophthalmia. Fortunately, the work of Crede, who developed prophylaxis with 2% silver nitrate in 1881, nearly eliminated visual loss from this disease in the West [11] . Unfortunately, conjunctivitis in the first month of life still remains a common threat to vision in much of the developing world. In areas without prophylaxis, the incidence of ophthalmia neonatorum is as high as 23%. In Africa, between 1 000 and 4 000 infants are blinded each year [12] . S. aureus is the most common organism causing neonatal conjunctivitis in most of the developing countries [10] . In one study in India S. epidermidis was the most common isolated bacterial species (28.6%) followed by S. aureus (10%) [13] . Amini et al. showed that E. coli was reported as the second most common cause (23%) of acute neonatal conjunctivitis after S. aureus (31%) in a five year study in Iran [14] . The exact determination of the etiology in neonatal conjunctivitis cases may help improve initial management and control, thereby preventing further complications. This study was performed to determine the prevalence of conjunctivitis and its bacteriological causes in neonates of two hospitals in Tehran.

2. Materials and methods

2.1. Study population

W e c o n d u c t e d o u r st u d y a t t h e n e o n a t a l w a r d s o f t w o hospitals in Tehran, over a period of 14 months (March 2008- May 2009). Of the 2 253 neonates (age range 1-30 days), 241 cases who presented with clinical findings of conjunctivitis

were included in this study. After informed consent from the mothers, a questionnaire was filled for each patient by members of the study team and microbiological tests were performed. Details of mode of delivery, age at presentation, gender, signs and symptoms (conjunctival erythema, swelling of the eyelids, mucopurulent discharge, unilateral/bilateral involvement, and other problems) were documented.

  • 2.2. Specimen collection

At the bedside, conjunctival specimens were taken by a trained person from each infant with two sterile swabs. Specimens were obtained from inferior conjunctival fornix f o r r o u t i n e b a c t e ri a l c u l t u r e a n d PCR f o r C. trachomatis. Specimens were obtained by swab from the conjunctiva of the everted lower eyelid using a sterile swab. A smear was made from the swab taken for chlamydia detection inside 2SP transport medium and the specimens transported to the laboratory.

  • 2.3. Specimens culture

The conjunctival scraping was inoculated at the bedside into a thioglycolate broth for detection of bacteria, the tubes were immediately transported to the laboratory and incubated at 37 ° C for a minimum of 24 h and cultured immediately on blood agar and chocolate agar. The plates were incubated

at 37 ° C in the presence of 5% CO 2 . The isolated bacteria i d e n t i f i e d u s i n g s t a n d a r d p r o c e d u r e s . L a b o r a t o r y

w e r e

d i a g n o sis wa s b a s e d o n Gr a m st a i n i n g , b a c t e ri a l c u l t u r e (u si n g c h o c o l a t e a g a r f o r N. gonorrhoea e a n d b l o o d a g a r for other bacteria. All isolates were identified according to conventional microbiological procedures.

  • 2.4. PCR

A gene amplification method that combines a PCR with measurement of PCR products was used to detect a conserved region of the major outer membrane protein (MOMP) gene. T h e s e p r i m e r s w e r e m a d e b y t h e M W G C o m p a n y :

5GATAGCCAGCACAAAGAGAGCTAA-3sense and 5-CTTTGTTTTC

GACCGTGTTTTGCAAACAGATGTGAA-3antisense.

CinnaGen DNA Purification Kit was used for extraction of DNA and CinnaGen PCR Master Kit was used for PCR reaction. A 50 µL lysate of target cellular material was amplified through 30 cycles (1 min denaturized at 94 ° C, 1 min primer annealing at 55 ° C and 1 min primer extension at 72 ° C) in a 100 µL master mix (PCR reaction buffer, dNTP, Tag DNA polymerase) and 0.5 µmol/L of primers that conserved MOMP nucleotide sequences of C. trachomatis. The band of PCR product was showed by electrophoreses. Positive control DNA was C. trachomatis-ATCC-VR 347. We found an 871 bp band on 1% agarose gel which had undergone electrophoresis for 2 h at 53 mA.

Seyed Abolfazl Afjeiee et al./Asian Pac J Trop Dis 2013; 3(6): 429-433

431

3. Results

This study was done on 241 neonates, 165 infants (67.2%) were from Mahdieh Hospital and 79 neonates (32.8%) from Mofid Ch il d r e n Ho s p it a l. On e h u n d r e d a n d t h irt y o n e n e o n a t e s (54.4%) were male, and 110 (45.6%) female. One hundred and seven babies (44.4%) had been delivered vaginally and 134 ( 5 5 . 6 % ) b y c e s a r e a n s e c t i o n . B i l a t e r a l c o n j u n c t i v i t i s w a s present in 59.3% of patients, and unilateral involvement was seen in 40.7% of the patients. Bacterial cultures were positive in 194 neonates (80.5%), but were negative in 47 (19.5%) neonates despite presence of conjunctivitis (Table 1). Among 194 neonates with bacterial conjunctivitis, 103 (53.1%) neonates were delivered by cesarean section and 91 (46.9%) were delivered vaginally. Bacterial conjunctivitis was unilateral in 77 (39.7%) neonates of those 194 neonates and it was bilateral in 117 (60.3%) of them. Erythema, discharge and swelling were present in 177 (91.2%), 161 (83.0%) and 157 (80.9%) cases. We found relation between the presence of discharge with neonatal bacterial conjunctivitis (P<0.04).

The most common organisms detected on conjunctival smears were Gram positive cocci in 56%, and coagulase- negative staphylococci were the leading bacteria grown on culture (n=130, 53.9%). The results of smears, bacterial cultures and PCR for chamydia are shown in Figure 1.

60 53.9 50 40 30 19.5 20 12.5 10 6.6 3.7 2.1 1.7 0 CN KP
60
53.9
50
40
30
19.5
20
12.5
10
6.6
3.7
2.1
1.7
0
CN
KP
NG
SBG
CBD
Other
Negative
Percentage

Figure 1. Results of bacterial culture in neonatal conjunctivitis (n=241).

C N : C o a g u l a s e - n e g a t i v e s t a p h y l o c o c c i , K P : Klebsiella pneumonia , N G :

  • N. gonorrhoeae , S B G : S t r e p t o c o c c u s B g r o u p , C B D : C o r y n e b a c t e r i u m

diphtheriae.

The most common risk factor in mothers was prolonged rupture of membranes found in 14 cases (5.8%). There were no significant differences in gender (P=0.14), mode of delivery (P=0.11) and history of prolonged rupture

Table 1 Demographic characteristic data and clinical manifestations of 241 neonates with conjunctivitis, March 2008- May 2009, Tehran, Iran.

 

Bacterial culture

Total

n=241

 

Patient characters

Negative

Positive

P value

n=47

n=194

Count (percent)

Count (percent)

Count (percent)

Hospital

Mofid

11 (23.4 % )

68 (35.1 % )

79 (32.8 % )

0.12

Mahdieh

36 (76.6 % )

126 (64.9 % )

162 (67.2 % )

Childbirth

NVD

16 (34.0 % )

91 (46.9 % )

107 (44.4 % )

0.11

C/S

31 (66.0 % )

103 (53.1 % )

134 (55.6 % )

Sex

Male

30 (63.8 % )

101 (52.1 % )

131 (54.4 % )

0.14

Female Eye involvement Bilateral

17 (36.2 % ) 26 (55.3 % )

93 (47.9 % ) 117 (60.3 % )

110 (45.6 % ) 143 (59.3 % )

0.53

Erythema

39 (83.0 % )

177 (91.2 % )

216 (89.6 % )

0.09

Discharge

33 (70.2 % )

161 (83.0 % )

194 (80.5 % )

0.04

Swelling

41 (87.2 % )

157 (80.9 % )

198 (82.2 % )

0.31

PROM

0 (0.0 % )

14 (7.2 % )

14 (5.8 % )

0.05

NVD: Normal vaginal delivery, C/S: Cesarean section, PROM: Premature rupture of membranes.

21 20 19 Negative 18 17 Postive 16 15 14 13 12 11 10 9 8
21
20
19
Negative
18
17
Postive
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
1.00
2.00
3.00
4.00
5.00 6.00
7.00
8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00
Age (days)
Count

Figure 2. The relationship between age and bacterial count of neonates with neonatal conjunctivitis, March 2008- May 2009, Tehran, Iran.

  • 432 Seyed Abolfazl Afjeiee et al./Asian Pac J Trop Dis 2013; 3(6): 429-433

o f

m e m b r a n e s ( P = 0 . 0 5 ) b e t w e e n n e o n a t e s w i t h p o s i t i v e

conjunctivitis remains controversial because it is frequently

o r

n e g a t i v e i n v e s t i g a t i o n s f o r b a c t e r i a l c o n j u n c t i v i t i s .

cultured from the eyes of asymptomatic neonates [10] . In the

T h e m e d i a n a g e a t p r e s e n t a t i o n

f o r a c u l t u r e p o s i t i v e

conjunctivitis was day 8 of life in neonatesages ranging from day 1 to day 30 (Figure 2).

4. Discussion

Neonatal conjunctivitis occurs in 1.6%-12.0% of newborns. A n y e y e i n f e c t i o n t h a t o c c u r s i n t h e f i r s t m o n t h o f a b a b y s l i f e i s d e f i n e d a s o p h t h a l m i a n e o n a t o r u m . T h e most common types of bacteria that cause infection in the infants eye come from the mothers birth canal. The most c o m m o n c a u s e is c h e m i c a l i r r i t a t i o n f r o m a n t i m i c r o b i a l prophylaxis against bacterial infection. In the present study t h e i n c i d e n c e o f n e o n a t a l c o n j u n c t i v i t i s w a s 1 0 . 7 % . T h e figures are similar to other reports, which quote rates from 1.6% to 12.0% of neonates [14] . Infected newborns usually develop drainage from the eyes in the first month of life [15] .

  • I n o u r s t u d y , m o s t o f t h e n e o n a t e s w i t h b a c t e r i a l conjunctivitis were between the ages of 1 and 12 days and with all three symptoms (erythema, swelling and discharge).

  • I n o u r s t u d y , t h e m i c o r g a n i s m s c a u s i n g n e o n a t a l c o n j u n c t i v i t i s w e r e c o a g u l a s e - n e g a t i v e s t a p h y l o c o c c i ,

    • C. trachomatis, Klebsiella pneumonia , Neisseria mucosa ,

Streptococcus B Group and Corynebacterium diphtheriae, respectively. In a study by Soltanzadeh et al., in which 170 of 3 140 of neonates (5.4%) had conjunctivitis signs, the most common

m i c r o b i a l o r g a n is m s we r e c o a g u l a s e n e g a t i v e st a p h y l o c o c c i

( 1 5 . 3 % ) , S. epidermidis

( 1 3 . 5 % ) , E. coli ( 7 . 6 % ) a n d C.

trachomatis (6.0%) [5] . In other study by Amini et al. in Iran the micro-organisms c a u s i n g 1 9 8 o f 4 0 2 1 ( 4 . 9 % ) n e o n a t a l c o n j u n c t i v i t i s w e r e

st u d y o f M o h i l M , t h e m o st c o m m o n m i c r o b i a l p a t h o g e n causing neonatal conjunctivitis was S. epidermidis (57.14%) a n d c o rr e s p o n d e d t o s o m e st u d i e s wh i c h s h owe d t h a t S. epidermidis is the most common organism causing neonatal c o n j u n c t i v i t is. E v e n t h o u g h S. epidermidis w a s t h e m o st commonly isolated bacterial species, the exact role of this

o r g a n i s m i n t h e c a u s a t i o n o f

c o n j u n c t i v i t i s i n n e w b o r n

babies remains unclear. These organisms might have been the pa rt o f the no rma l fl o r a tha t is in the inf ants [13] . The Neisseria mucosa and Corynebacterium diphtheriae isolates were also most likely part of the normal conjunctival flora. Go n o c o c c a l o p h t h a l m i a n e o n a t o r u m h a s a n i n c i d e n c e o f 0.3/1 000 in live births in the United States [17] . In Dr. Aminis st u d y o f n e o n a t a l c o n j u n c t i v i t is i n Ir a n t h e i n c i d e n c e o f g o n o c o c c a l o p h t h a lmi a wa s 3% [14] , h owe v e r i n o u r st u d y , although prophylaxis treatment of gonorrhea for newborn is n o t u s e d i n t h e s e two h o s p i t a l , n o c a s e o f g o n o c o c c a l o p h t h a l m i a w a s d e t e c t e d u s i n g s t a n d a r d p r o c e d u r e s f o r d e t e c t i o n o f N. gonorrhea i n c l u d i n g G r a m s t a i n i n g a n d culture. The results of this study clearly demonstrated that the frequency of neonatal conjunctivitis is significantly high (10.7%) in Iran. Bacteria could be isolated from 80 percent of the patients with clinical signs of conjunctivitis.

Conflict of interest statement

We declare that we have no conflict of interest.

Acknowledgements

We thank the Pediatric Infections Research Center for

  • S. aureus , ( 3 1 % ) , Escherichia coli ( 2 3 % ) , S. epidermidis ,

t h e f i n a n c i a l s u p p o r t . W e a ls o t h a n k a l l t h e n u rs e s a n d

( 2 2 % ) , Klebsiella pneumoniae ( 1 0 % ) , N. gonorrhea ( 3 % ) ,

o t h e r p r a c t i c e s t a f f i n n e o n a t a l w a r d s o f M a h d i e h

a n d

Pseudomonas aeruginosa ( 2 % ) a n d C. trachomatis ( 2 % )

Mofid hospitals, who have kindly assisted us by collecting

respectively [14] . In a study by Iroha Eo and his colleagues

s a m p l e s f r o m n e o n a t e s . A p a r t o f t h i s s t u d y

h a s b e e n

i n 1 9 9 8 o n 1 5 0 h o s p i t a l i z e d n e o n a t e s , t h e p r e v a l e n c e o f c o n j u n t i v i t i s w a s r e p o r t e d a s 1 . 8 % t h a t t h e i r m i c r o b i a l

p r e s e n t e d i n t h e F i r s t I n t e r n a t i o n a l S c i e n c e S y m p o s i u m on HIV and Infectious Diseases (HIV SCIENCE 2012) Chennai,

c a u s e s w e r e S. auerus ( 3 7 . 4 % ) , Klebsiella pneuomoniae ( 1 2 . 9 % ) , a n d S. coagulase n e g a t i v e ( 1 2 . 3 % ) . T h e c a u s e o f l o w e r p r e v a l e n c e i n s t u d y o f I r o h a c a n b e d u e t o s m a l l

India, 20-22 January 2012.

samples or due to study of only hospitalized patients that

Comments

the researchers had found lower positive cases [16] . S. aureus was the most common organism cultured from neonates with acute conjunctivitis, but its role in neonatal

Background Neonatal conjunctivitis is one of the important systemic

Seyed Abolfazl Afjeiee et al./Asian Pac J Trop Dis 2013; 3(6): 429-433

433

complications. It causes visual loss if not treated promptly, m o s t c o m m o n e t i o l o g i c a g e n t i s N. gonorrhoeae , C. trachomatis and herpes virus. Global prevalence of neonatal conjunctivitis is less than 0.5 percent per 1 000 population, Pakistan and Africa show higher percentage of morbidity when compared to others.

Research frontiers I n c i d e n c e s o f n e o n a t a l c o n j u n c t i v i t i s w e r e 3 5 . 1 % a n d 64.9% in both Mofid and Mahdieh hospitals from 2008-2009 in Iran.

Related reports

A recent article published similar methods in the same g e o g r a p h i c a l r e g i o n , it wa s f o u n d t h a t 2 2 6 / 5 2 0 6 n e o n a t e s had signs of conjunctivitis. Among these, bacterial cultures w e r e p o s i t i v e i n 1 4 8 , t h e m a j o r c a u s a t i v e a g e n t s a r e N. gonorrhoeae, a n d C. trachomatis. P r o p h y l a c t i c m e a s u r e s and treatment for pregnant women were surmised.

Innovations & breakthroughs This study revealed two aspects of infections. There is no significant difference between caesarian and normal vaginal d e l i v e r y . E n t e r i c p a t h o g e n s a n d G r a m - p o si t i v e b a c t e r i a play a major role which is due to premature rupture of the membrane and skin contamination. This study reiterates the importance of screening pregnant women for C. trachomatis a n d o t h e r s e x u a l l y tr a n smi t t e d d is e a s e s j u st p ri o r t o t h e birth of a child.

Applications

T h i s

s t u d y e m p h a s i s e s t h e i m p o r t a n c e o f f o c u s i n g

o n n e o n a t a l c o n j u n c t i v i t i s . I n a d d i t i o n , s c r e e n i n g a n d

prophylactic measures are needed for pregnant women prior to the birth of the baby.

Peer review T h i s i s a g o o d s t u d y w h i c h r e v e a l s t h e i n c i d e n c e

o f

t h e n e o n a t a l c o n j u n c t i v i t i s i n b o t h h o s p i t a l s . B a c t e r i a l etiologic agents were discussed. The authors have screened t h e e ti o l o g i c a g e n ts o f n e o n a t a l c o n j u n c ti v itis fr om t h e ir

g e o g r a p h i c a l r e g i o n s .

T h e

a r t i c l e

c r e a t e s

outcome towards the treatment.

s i g n i f i c a n t

References

[1]

G u l S S , J a m a l M , K h a n N . O p h t h a l m i a n e o n a t o r u m . J Coll Physicians Surg Pak 2010; 20(9): 595-598.

[2] R i c h a r d s A, Gu z m a n - C o t tri l l JA. C o n j u n c t i v i t is. Pediatr Rev

[3]

2010; 31(5): 196-208.

W a d h w a n i M , D s o u z a P , J a i n R , D u t t a R , S a i l i A , S i n g h A . Conjunctivitis in the newborn-a comparative study. Indian J Pathol Microbiol 2011; 54(2): 254-257.

[4] N aito T, Aoki K, Ohguchi T, Ohgami K, Ohno S, Shiot H, et al.

[5]

[ P a t h o g e n e s i s o f i n f e c t i o u s c o n j u n c t i v i t i s i n N e p a l ] . Nihon Ganka Gakkai Zasshi 2009; 113(11): 1088-1091. Japanese. E pling J. Bacterial conjunctivitis. Clin Evid 2007; 20: 2012.

[6] S ilverstein BE, Morris TW, Gearinger LS, DeCory HH, Comstock TL. Besifloxacin ophthalmic suspension 0.6% in the treatment of bacterial conjunctivitis patients with Pseudomonas aeruginosa infections. Clin Ophthalmol 2012; 6: 1987-1996. [7] C h i k v i l a d z e D , N i k u r a d z e N , G a c h e c h i l a d z e K h , M i q e l a d z e M , M e t r e v e l i D . [ M i c r o b i a l s t r u c t u r e o f a c u t e b a c t e r i a l conjunctivitis]. Georgian Med News 2013; 216: 12-15. Russian. [8] R ours IG, Hammerschlag MR, Ott A, De Faber TJ, Verbrugh HA, de Groot R, et al. Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants. Pediatrics 2008; 121(2): 321-326. [9] G o o d y e a r - S m i t h F . W h a t i s t h e e v i d e n c e f o r n o n - s e x u a l transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forensic Leg Med 2007; 14(8): 489-502. [10] C h a n g K , C h e n g V Y W , W o n g N S K . N e o n a t a l h a e m o r r h a g i c c o n j u n c t i v i t is: a s p e c i f i c si g n o f c h l a m y d i a l i n f e c t i o n . Hong Kong Med J 2006; 12: 27-32. [11] N apchan BM, Morales RP, Carvalho ML, Cunha KV, Figueras A. From suspicion to action: the chemical conjunctivitis and silver nitrate connexion Brazilian hospitals. Pharmacoepidemiol Drug

Saf 2005; 14: 555-969.

[12] D avid M, Rumelt S, Weintraub Z. Efficacy comparison between p o v i d o n e i o d i n e 2 . 5 % a n d t e t r a c y c l i n e 1 % i n p r e v e n t i o n o f ophthalmia neonatorum. Ophthalmology 2011; 118(7): 1454-1458. [13] M o h i l e M, De o r a ri As h o k K, S a t p a t h y G, S h a r m a A, S i n g h M. M i c r o b i o l o g i c a l st u d y o f n e o n a t a l c o n j u n c t i v i t is w i t h s p e c i a l reference to Chlamydia trachomatis. Indian J Ophthalmol 2002;

50: 295-299.

[14] A m i n i

E ,

G h a s e m i

M ,

D a n e s h j o u

K .

A

f i v e - y e a r

s t u d y

o f

ophthalmia neonatorum in Iran: prevelence and etiology. Clin

Med 2008; 14(2): 90-96.

[15] M ohan H, Verma J, Singh I, Mohan P, Marwah S, Singh P. Inter- relationship of zinc levels in serum and semen in oligospermic infertile patients and fertile males. Indian J Pathol Microbiol

1997; 40: 451-455.

[16] I r o h a E O , K e s a h C N . B a c t e r i a l e y e i n f e c t i o n i n n e o n a t e s a prospective study in a neonatal unit. West Afr J Med 1998; 17(3):

168-172.

[17] D arville T. Neisseria gonorhoeae. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson textbook of pediatrics. Philadelphia:

WB Saunders; 2008, p. 1169-1173.