Gonococcal eye prophylaxis—are mandates still justified?

Introduction

Credé reported in 1881 that the instillation of 2% silver nitrate drops into the eyes of newborn infants reduced the incidence of gonococcal ophthalmia neonatorum. However, much has changed over the 140 years since this study was published. At the beginning of the 20th century, before expectant mothers were being screened for sexually transmitted infections (STIs), the term ophthalmia neonatorum was, for all practical purposes, synonymous with gonococcal conjunctivitis. As neonatal conjunctivitis came under control with silver nitrate prophylaxis, the importance of another form of ophthalmia neonatorum, inclusion blennorrhea (later identified as being due to Chlamydia trachomatis ), was noted. The relationship between maternal genital infection and conjunctivitis of the newborn with inclusion bodies within epithelial cells was established by Thygeson and Stone in 1942. Penicillin first became available to treat patients in the 1950s, which allowed for the treatment of gonococcal infection. Gonococcal ophthalmia became and still is very uncommon due to the introduction of prenatal screening for Neisseria gonorrhoeae and treatment of pregnant women. C. trachomatis was the most common cause of neonatal conjunctivitis in the United States in the latter half of the 20th century before the Centers for Disease Control and Prevention (CDC) recommended routine prenatal screening of pregnant women for C. trachomatis in 1993, which has resulted in a dramatic decrease in perinatal chlamydial infection, including conjunctivitis, in the United States. Currently, erythromycin ophthalmic ointment is the only preparation available for neonatal ocular prophylaxis in the United States. Tetracycline ophthalmic ointment is no longer manufactured, and silver nitrate has not been available for over 2 decades. Many hospitals in the United States had switched to erythromycin ophthalmic ointment by the 1980s. Neonatal ocular prophylaxis with erythromycin is also specifically mandated by law in many states. However, neonatal ocular prophylaxis with erythromycin or tetracycline ophthalmic ointment does not prevent chlamydial ophthalmia.

The CDC and the U.S. Preventive Services Task Force (USPSTF) currently recommend neonatal ocular prophylaxis with erythromycin ophthalmic ointment primarily for prevention of gonococcal ophthalmia. ^, Several countries in Europe (e.g., United Kingdom, Germany, Norway, Sweden, Denmark) have discontinued universal ocular prophylaxis and others offer parental choice. ^, The World Health Organization (WHO) still recommends neonatal ocular prophylaxis for the prevention of both gonococcal and chlamydial ophthalmia. In 2015, the Canadian Pediatric Society recommended discontinuation of routine neonatal ocular prophylaxis in Canada, with an emphasis on enhanced prenatal screening for gonorrhea and C. trachomatis .

Given the changed epidemiology of ophthalmia neonatorum in the United States and the impact of prenatal screening and treatment of pregnant women for N. gonorrhoeae , the question of whether mandates for ocular prophylaxis for the prevention of neonatal gonococcal ophthalmia in the United States are still necessary should be reevaluated.