Year : 2014 | Volume
: 21 | Issue : 3 | Page : 203--204
Ophthalmia neonatorum prophylaxis and the 21 st century antimicrobial resistance challenge
Division of Ophthalmology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Stellenbosch, South Africa
Prof. David Meyer
Division of Ophthalmology, Faculty of Health Sciences, University of Stellenbosch
|How to cite this article:|
Meyer D. Ophthalmia neonatorum prophylaxis and the 21 st century antimicrobial resistance challenge.Middle East Afr J Ophthalmol 2014;21:203-204
|How to cite this URL:|
Meyer D. Ophthalmia neonatorum prophylaxis and the 21 st century antimicrobial resistance challenge. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2021 Dec 1 ];21:203-204
Available from: http://www.meajo.org/text.asp?2014/21/3/203/134667
In 1874, the incidence of ophthalmia neonatorum in the maternity hospital in Leipzig, Germany, where Dr. Carl Siegmund Franz Credé (1819-1892)  served as the professor of obstetrics, amounted to a staggering 13.6%. This disturbed the dedicated professor as the principal cause of blindness in infancy was due to gonoccocal ophthalmia neonatorum (neonatal conjunctivitis). He then instituted the following regime: "After the ligature and division of the umbilical cord we first removed from the children in the usual manner the sebaceous matter and the blood, mucus, etc., which clung to them; then they were brought to the bath and there, by means of a clean piece of cloth … (and) ordinary water, their eyes were cleansed on the outside…Then on the table … each eye is opened by means of two fingers, a single drop of a 2 per cent solution of silver nitrate hanging on a little glass rod is brought close to the cornea until it touches it, and is dropped on the middle of it. There is no further care given to the eyes. Especially in the next twenty-four to thirty-six hours, in case a slight reddening or swelling of the lids with secretion of mucus should follow, the instillation should not be repeated."  (translated from the original German text). Subsequently, he reported in 1881, on the first 1160 infants treated in this way and showed that the incidence of gonoccocal ophthalmia neonatorum was dramatically reduced to 0.15%. History has proven that this indeed was a genial step taken by a bold obstetrician in an era when ignorance about microbiological concepts widely existed.
Credé used 2% silver nitrate and his report admits to the chemical conjunctivitis side effects, which typically manifests in the first 24-36 hours after instillation. For many decades, Credé's solution was globally the standard for prophylactic care of the eyes of the newborn. As medical science progressed and knowledge of bacteriology and antibiotics improved, a slow international shift away from 2% silver nitrate solution as prophylaxis occurred. This "primitive" solution was replaced by newer topical antibiotics such as chloramphenicol, tetracycline, and erythromycin.
Today, we need to ask ourselves whether ophthalmia neonatorum prophylaxis may be achieved as or even more effectively without the widespread use of antibiotics?
Why should we consider this question at all?
The significance of this question is emphasized by the 2014 World Health Organization (WHO) report entitled, "Antimicrobial resistance Global report on surveillance".  This report reminds all clinicians across all disciplines of medicine that antimicrobial resistance (AMR) within a wide range of infectious agents is a growing worldwide public health threat. The risk is so serious that "it threatens the achievements of modern medicine". The WHO report warns that "a post-antibiotic era-in which common infections and minor injuries can kill-far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century". Should this threat materialize, it will impact negatively on the achievement of the Mellenuim Development Goals agreed upon by the United Nations countries. This report highlights the fact that decreased resistance of Neisseria gonorrhoeae to third-generation cephalosporins (the last resort for treatment of gonorrhea) has been verified in 36 countries. This organism is the one Professor Credé attempted to eliminate from the eyes of his neonates. Warnings have also sounded pertaining to the rising wave of resistance against the most favored modern antibiotics in ophthalmology-the fluoroquinolones. 
WHO further reports that each year some 340 million new cases of syphilis, gonorrhea, chlamydia, and trichomoniasis occur in men and women aged 15-49. Overall, sexually transmitted disease prevalence rates continue to rise in most countries.  The shedding of herpes simplex virus 2 (HSV-2) as well as the human immuno virus (HIV) in the birth canal is also increasing. The overall prevalence of HSV-2 infection among antenatal women presenting at public healthcare clinics in four pilot provinces in South Africa in 2012 was estimated to be 55.8% (95% CI: 55.1-56.5%).  Sub-Saharan Africa remains the epicenter of the HIV and acquired immunodeficiency syndrome (AIDS) epidemic and accounts for nearly 70% of the world burden. Currently, antibiotic prophylactic regimes do not eliminate many of these birth canal organisms. In this issue, Ranjit et al., reports about the "Maternal and Neonatal Risk Factors associated with Vertical Transmission of Neonatal Conjunctivitis in Neonates" in the developing Sub-Saharan country of Malawi and highlights the different treatment regimes for the condition. As ophthalmologists, we dare not neglect our responsibilities as members of health teams to adequately assist in the prevention of neonatal conjunctivitis with its potential blinding consequences. A widely used and recognized topical agent in ophthalmology is povidone-iodine. The use of this solution rather than antibiotics for the prophylaxis of ophthalmia neonatorum should be encouraged universally for the following reasons: 
Its efficacy against a wide range of organisms including bacteria, fungi, chlamydiae, HSV-2, and HIV.
In a 2.5% solution, povidone-iodine is relatively non-toxic and well-tolerated by the sensitive eyes of neonates.
The conjunctiva appears brown after instillation into the conjunctival sack, and this assists to ensure adequate application by the nursing staff.
The cost of this solution is affordable all over the world, and this fact alone should encourage its widespread acceptance and use as an ocular anti-infectious agent.
Perhaps most importantly, the absence of true antimicrobial resistance to the compound,  which in the view of the 2014 WHO report on AMR, should be a key factor in encouraging its use.
The future generations who will inhabit this planet will be indebted to us if we responsibly use every milligram of antimicrobial agent available today.
|1||Available from: http://en.wikipedia.org/wiki/Carl_Siegmund_Franz_Cred%C3%A9 [Last accessed on 2014 Jun 05].|
|2||Credé CS. The prevention of eye inflammation in the newborn. Arch Gynaecol 1881;17:50-3.|
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|5||Available from: http://www.afro.who.int/en/clusters-a-programmes/frh/sexual-and-reproductive-health/programme-components/control-of-sexually-transmitted-and-reproductive-tract-infections-and-hivaids.html [Last accessed on 2014 Jun 05].|
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