ORIGINAL

Niger J Paed 2013; 40 (4): 360 –363

Mohammed A

Asani M

Ibrahim M

Bacterial agents and sensitivity

pattern of neonatal conjuctivitis in

Aminu Kano Teaching Hospital

DOI:http://dx.doi.org/10.4314/njp.v40i4,2

Accepted: 27th May 2013

Abstract Introduction: In Africa

alone, between 1000 – 4000 chil-

dren are blinded annually by

conjunctivitis. In view of the

changing aetiological agents

documented in other parts of the

world and evolving resistance of

infective agents to therapeutic

agents, the present study was

designed to define the bacterial

agents, their antibiotic sensitivity

pattern seen in AKTH, Kano,

Nigeria.

Patients and methods: This was a

cross sectional prospective study

done over a period of 3 months.

Consecutive neonates who satis-

fied the inclusion criteria were

recruited until the sample size of

technique.

Results: The mean age at presenta-

tion was 5.7 ± 4.6days. Results of

the eye swabs showed that 97

(55.4%) were bacteriologically

positive while 78 (44.6%) yielded

no growth. Staphylococcus aureus

was the most frequently isolated

organism and was most sensitive

to ceftriaxone, (73.1%). Es-

cherichia coli was most sensitive

to gentamicin (78.3%). Pseudomo-

nas aeruginosa and Neisseria gon-

orrhea showed 100% sensitivity to

ceftazidime and ceftriaxone re-

spectively.

(

)

Mohammed A

Asani M, Ibrahim M

Department of Paediatrics,

Aminu Kano Teaching Hospital,

Kano Nigeria.

E-mail: muhdpaed@yahoo.com

Conclusion: Staphylococcus

aureus is the commonest bacterial

agent responsible for neonatal con-

junctivitis. Staphylococcus aureus

was most sensitive to ceftriaxone.

1

75 was obtained. samples were

transported to the laboratory

within one hour. Gram staining

and antibiotic sensitivity were

determined using standard

Key words: Conjuctivitis,

Neonates, Bacteria, Sensitivity.

Introduction

disease agents (Chlamydia trachomatis and Neisseria

gonorrhoea), microorganisms from the skin

(Staphylococcus aureus) and the mother’s gastrointesti-

nal tract (Pseudomonas spp and Escherichia coli) and

Haemophilus influenzae among others. Neisseria gonor-

rhoea is an important aetiological agent of neonatal con-

Neonatal conjunctivitis was originally described in 1750

by Quellmaz. It is one of the most common infections

1

occurring in the first month of life and remains an im-

portant cause of ocular morbidity of great health con-

2

3

6

cern . Faal noted that there were an estimated one and a

half million blind children in the world in 1992 and

every year about half a million more became blind. Neo-

natal conjunctivitis was responsible for blindness in the

majority of these children in countries of Asia and Af-

junctivitis because of its potential damage to vision. It

accounts for up to 1.7% of all neonatal conjunctivitis

7

recorded in the study from Benin, Nigeria. However the

introduction of prophylactic measures has led to a de-

crease in the incidence₈of gonococcal and chlamydial

neonatal conjunctivitis. Recent studies show that

Staphylococcus aureus appears to be increasingly a

common causative agent of neonatal conjunctivitis. It

3

rica and. In Africa between 1000 – 4000 children suf₄fer

blindness annually as a consequence of conjunctivitis.

7

The major causes of neonatal conjunctivitis are, in de-

creasing order of frequency, chemical inflammation,

bacterial infections and viral infections while bacteria

are the major causes of infectious neonatal conjunctivi-

accounted for 60.5% of cases seen in Benin, and 42.4%

6

of cases seen in Abakaliki both in Nigeria.

In view of the changing aetiological agents documented

in Nigeria and other parts of the world as well as

5

tis. The bacterial causes include sexually transmitted

3

61

evolving resistance of infective agents to routinely used

therapeutic agents and the paucity of information on

neonatal conjunctivitis in Nigeria, the present study was

designed to identify the bacterial agents, their antibiotic

sensitivity pattern and ocular clinical presentation of

neonatal conjunctivitis among newborn babies seen in

AKTH.

fixed using heat and alcohol. Gram staining of the slides

was carried out using standard techniques. The swabs

were also inoculated on the chocolate agar plates and

o

were incubated for 24-48 hours at 37 C. Aerobic isolates

were id₀entified by the standard methods of Cowan

1

(1974). Anaerobes were not studied due to lack of fa-

cilities. Antibiotic sensitivity of the isolates was₁ deter-

1

mined using standard disc diffusion technique. How-

ever antibiotic sensitivity for Chlamydia was not done

due to lack of facilities. Diagnosis of chlamydial infec-

tion was done through detection of Chlamydial antigens

using a rapid immunochromatographic technique (ICT).

After collection of specimens, patients were managed in

accordance with standard departmental guidelines.

Subjects and methods

This was a cross sectional, prospective study in which

subjects were recruited over a period of three months

(

April to June 2010). Approval was obtained from the

Ethics Committee of Aminu Kano Teaching Hospital

and informed and written consent of the primary care

givers of subjects were obtained. Aminu Kano Teaching

Hospital (AKTH) is located in Kano metropolis. It is a

tertiary centre with a bed capacity of 500. The catch-

ment areas of the hospital include Jigawa, Bauchi ,

Katsina and Yobe states. The paediatric department of

the hospital consists of five units; the Special Care Baby

Unit, the Emergency Paediatric Unit, Paeditric Medical

Ward, Paediatric Outpatient Unit and Paediatric Spe-

cialty Clinic. The SCBU is located adjacent to labour

room and it consists of the inborn unit for neonates de-

livered in the hospital and out born unit for neonates

delivered outside the hospital who require

The data generated were entered into a Microsoft Excel

spreadsheet and analyzed using EPI INFO version 3.5.1

2002. Continuous variables were summarized using

means, medians, and ranges as appropriate. Frequency

tables were generated and cross–tabulations to observe

the relationship between categorical variables were

done. Proportions were compared using Chi-square test

of significance. A probability (p–value) of less than 0.05

was considered statistically significant.

Results

hospitalization.

A total of one hundred and seventy five (175) neonates

that met the study criteria were studied. The age range of

subjects at presentation was 1-24 days with the mean of

5.7 ± 4.6 days. Ninety one (52.0%) neonates were males

while eighty four (48%) were females with a male: fe-

male ratio of 1.1:1. A total of 1602 neonates were seen

in AKTH during the study period thus giving an inci-

dence of neonatal conjunctivitis of 60.5 per 1000 live

births in this study.

Consecutive neonates who satisfied the inclusion criteria

were recruited from the Special Care Baby Unit, the post

natal ward and paediatric outpatient unit of the hospital

until the desired sample size of 175 was obtained. The

sample size was determined based on the highest preva-

lence of positive bacterial isolates of 13.15% reported

2

from Ilorin. Inclusion criteria were: all babies within

the age of 0 –28 days presenting at Special Care Baby

Unit, paediatric outpatient unit, the postnatal ward and

labour ward with discharge from one or both eyes.

Relevant information was collected using a pre-tested

questionnaire administered to caregivers in interview

sessions. Birth weight was recorded for all inborn ba-

bies and for those delivered in other hospitals where the

information was available. For those without birth re-

cords the weight and age at presentation were deter-

mined.

Table 1: Distribution of age at onset of conjunctivitis

Age in

days#

Total

Number

Sex

Male

%

Female

%

0

3

6

– 2

– 5

– 14

14

82

76

10

7

47

39

5

26.8

22.3

2.9

-

35

37

5

20

21.1

2.9

4.0

>

-

7

Total

175

91

52

84

48

#

The unequal age intervals were used to reflect the incubation

periods of common aetiologic agents of neonatal

conjunctivitis.

Physical examination was conducted on all study sub-

jects and the severity of the conjunctivitis was scored

in each case using the method described by Christian.

9

Table 2: shows the bacterial agents isolated in neonates

with conjunctivitis. Results of the eye swabs showed

that 97 (55.4%) were bacteriologically positive while 78

Scores were awarded as 1+, 2+ and 3+ for mild, moder-

ate and severe cases respectively. Conjunctival swabs

were collected from the eyes of the subjcts with the aid

of sterile swab sticks and samples were then immersed

in the broth in universal bottles and transported to the

laboratory within 30 minutes to one hour. The broth

consists of peptone, Beef extracts and sodium chloride

which serve as nutrient for the pathologic organisms.

(

44.6%) yielded no growth. Six bacterial genera were

isolated, of which Staphylococcus aureus was the most

frequently isolated organism. Klebsiella species and

Neisseria gonorrhoea were the least isolated organisms

accounting for 1.7% each.

Smears of the specimens were made on glass slides and

3

62

Table 2: Bacterial isolates and Chlamydia antigen positivity

in neonates with conjunctivitis.

ceftriaxone, recorded in 38 cases (73.1%), followed by

gentamicin and ceftazidime in 32 cases (61.5%) and 30

(

57.7%) cases each. Escherichia coli was most sensitive

Bacteria isolated

Frequency Percent of total

to gentamicin observed in 18 (78.3%) cases, followed by

ceftazidime, ceftriaxone and ofloxacin with 17 (73.9%),

Staphylococcus aureus

Escherichia coli

Pseudomonas aeruginosa

Chlamydia trachomatis

Klebsiella spp

52

23

11

5

3

29.7

13.1

6.3

2.9

1.7

1

5 (65.1%) and 12 (52.2%) cases respectively.

Sensitivity of Neisseria gonorrhoea to ceftriaxone was

demonstrated in all the 3 (100%) cases but it was

resistant to ceftazidime, erythromycin, ofloxacin, cipro-

floxacin, augmentin and amoxicillin.

Neisseria gonorrhoea

No growth

1.7

44.6

78

Total

175

100

Antibiotic sensitivity of bacterial agents isolated

The sensitivity of 92 bacterial agents isolated was tested.

Staphylococcus aureus was most sensitive to

Table 3: Antibiotic sensitivity pattern of bacterial isolates seen in neonatal conjunctivitis

Antibiotics

Organisms

No of

AMX

AUG

CPF

CTR

OFL

ERY

GEN

CTZ

CPC

LEV

isolates

SA

ECO

CHL

52

23

5

3(5.8)

1(4.3)

NT

11(21.1)

1(4.3)

NT

11(21.1)

10(43.5)

NT

38(73.1)

15(65.2)

NT

11(21.1)

12(52.2)

NT

10(10.9)

-

NT

32(61.5)

18(78.3)

NT

30(57.7)

17(73.9)

NT

20(38.5)

3(13.0)

NT

8(15.4)

4(17.4)

NT

PSEUD

KLEB

NEISS

11

3

-

1(33.3)

-

1(33.3)

-

4(36.4)

1(33.3)

3(100)

-

4(36.4)

1(33.3)

11(100)

2(66.7)

-

5(45.5)

-

1(33.3)

2(18.2)

-

1 (33.3)

Total

97

4(4.3)

14(15.2)

22(23.9)

61(66.3)

23(25.0)

10(10.9)

56(60.9)

60(65.2)

29(31.5)

15(16.3)

AMX=Amoxicillin AUG=Augmentin ERY=Erythromycin GEN=Gentamicin CPC=Chloramphenicol CTZ=Ceftazidime OFL = Ofloxacin NT=

Not tested

LEV=Levofloxacin CPF=Ciprofloxacin CTR=Ceftriaxone ns=number sensitiveNT = Not tested

The predominance of Staphylococcus aureus in this

study may suggest that most of the cases of neonatal

conjunctivitis were postnatally acquired rather than d₇ur-

1

Discussion

ing passage through the birth canal. Ibrahim et al in

Kano also reported S. aureus as the dominant isolate

(42.1%) among neonates from a study of bacteramia

among febrile children aged 0-14 years conducted over a

period of one year. Virulence factors possessed by

S. aureus make it to be the comm₁o₈nest agent of infec-

tion in children including neonates.

The mean age at presentation of 5.7 days of the neonates

with neonatal conjunctivitis in this study is similar to 4.6

days observed in Abakaliki, Nigeria, by Ibekwe. It is

6

1

3

however lower than 12.9 days documented by Ugbode

from Zaria (Nigeria) . On the other hand, it₄is slightly

1

higher than five days obtained by Abdulkadir in a later

Zaria study in 2008. The incubation period of the pre-

dominant aetiological agent in a locality may partly ex-

plain the difference in age at presentation.

The positive isolate rate of (13.1%) for Escherichia coli

in neonatal conjunctivitis found in this study is compara-

19

7

ble to the report by Kolade and Iyamu et al from Ilorin

and Benin who found positive isolate rate of 10.08% and

12.5% for E. coli respectively. It is however higher than

The male to female ratio in the current study of 1₆.1:1 is

similar to the 1.2:1 ratio recorded by Ibekwe from

6

6.1% reported by Ibekwe et al. A low rate of Neisseria

1

3

Abaka₅liki but differs from that of Olatunji and Mohile

gonorrhoea (1.7%) neonatal conjunctivitis was found in

1

et al who documented a male: female ratio of 1:1.5. It

this study. This is similar to 1.6% positive isolate rate

7

is howev₂er lower than the ratio of 1.5:1 recorded by

recorded by Iyamu from₁₉Benin but higher than 0.84%

1

Ugbode from Zaria, Nigeria. Males have approxi-

rate reported by Kolade from Ilorin It may be sug-

gested that the low rate N. gonorrhoea obtained in this

study may be due to availability of health facilities and

improved health habits. It may also be due to fastidious

nature of N. gonorrhea

mately twofold higher incidence of sepsis than females

suggesting the possibility o₆f a sex-linked factor in host

1

susceptibility to infection. Staphylococcus aureus was

the most commonly isolated bacterium in this stu₂dy.

1

This was in keeping with the findings of Ugbode in

7

Zaria as well as Iyamu and Enabule in Benin City.

Staphylococcus aureus showed a good sensitivity to

2

However, it differed from that of Ernest who recorded

ceftriaxone (73.1%) and ceftazidime (57₁.7%). This find-

2

Chlamydia trachomatis as the predominant organism of

ing is in keeping with that by Schobers. The sensitivity

neonatal conjunctivitis in Ilorin.

rate of Staphylococcus aureus to gentamicin in₀ this

2

study (61.5%) is lower than the findings of Kolade and

3

63

2

Onile et al who reported much higher sensitivities of

9.29% and 100% respectively. It is however higher

Conclusion

8

6

than 42.8% reported by Ibekwe from Abakaliki. The

relatively high sensitivity of Staphylococcus aureus to

ceftriaxone, ceftazidime and gentamicin could be ex-

plained by low potential for abuse as these drugs are

present only in injectable and topical forms.

Staphylococcus aureus and Escherichia coli are the

commonest bacterial agents responsible for neonatal

conjunctivitis in Aminu Kano Teaching Hospital. We

therefore, recommend the use of Ceftriaxone and topical

Gentamycin to treat neonatal conjunctivitis in

Kano.Periodic survey should also be carried out to iden-

tify any change in the aetiological agents of neonatal

conjunctivitis so as to guide modification in the treat-

ment plan of the disease.

Escherichia coli showed a high sensitivity of 78.3% to

gentamicin which is ho₆wever, lower than the 100% re-

ported by Ibekwe et al. The sensitivity of Escherichia

coli to ceftazidime(73.9%) and ceftriaxone(65.2%) is

1

9

similar to the report of Kolade. Neisseria gonorrhoea

was highly sensitive to ceftriaxone (100%). The higher

sensitivity of E. coli to these antibiotics may be due to

the fact that they are present only in injectable forms,

hence not commonly abused, thus less likelyhood of

resistance.

Conflict of interest: None

Funding: None

References

1

2

.

Kaivonen M. Prophylaxis of oph-

thalmia neonatorum Acta Ophthal-

mol 1965:Suppl 79 : 1 –7.

Ernest SK, Adeniyi A, Mokuolu

OA, Onile BO, Oyewale B. Neo-

natal conjunctivitis in Ilorin, Nige-

ria. Niger J Paediatr 2000;27:39-

9. Christian RJ: Comparism of ocular

16. Mohile M, Deorari AK, Satpathy

G, Sharama A, Singh M. Microbi-

ological study of neonatal conjunc-

tivitis with special reference to

Chlamydia trachomatis. Indian J

Ophthalmol 2002; 50:295-9.

reactions with the use of silver

nitrate and erythromycin ointment

in Ophthalmia neonatorum pro-

phylaxis. J Paediatr 1960; 57(1):

55 – 60.

10. Cowan ST: Cowan and Steel’s

manual for ide_nn_d tification of medi-

cal bacteria. 2 ed.

11. Cambridge University Press, Cam-

bridge, London. 1985; 138-39.

12. Bauer AW, Kirby WM, Sherris JC,

Antibiotic susceptibility testing by

a standardized single disc method,

Ann Pathol 1966; 45:493.

13. Ugbode RO. Prevalence of Oph-

thalmia neonatorum at the Ahmadu

Bello University Teaching Hospi-

tal Zaria. Dissertation presented to

the Faculty of Paediatrics, West

African College of Physicians,

1991.

17. Gotoff SP: Infection of the neona-

tal infant. In: Behrman ER, Klieg-

man MR, Jenson BH (editors)

Nelson Textbook of Paediatrics

4

6.

3

4

.

Faal HB. Childhood Blindness:

causes and prevention strategies

Postgrad Doct Africa 1992; 114

th

16 ed. Philadephia: WB Saunders

(3): 47-50.

Co. (Pub). 2000; 538-552.

18. Ibrahim M, Ibrahim A, Kashibu E,

Shehu UA. Bacteraemia in febrile

children as seen at Aminu Kano

Teaching Hospital, Kano. PAN-

Isenberg, Apt L, Wood MA. Con-

trolled trial of povidene iodine

prophylaxis against ophthalmia

neonatorum. N Eng J Med 1995;

st

3

32:562 –566.

CONF 2010 41 Annual General

5

6

.

Malika PS, Asok T, Aziz S, Faisal

HA, Tan AK, Intan G. Neonatal

conjunctivitis – a review. Malay-

sian Family Physician. 2008; 3

Scientific Conference Abstracts : 8

-9.

19. Vedantham V Prohylaxis of oph-

thalmia neonatorum. Br J Ophthal-

mol 2004; 88:1352-3

(2):77-81.

Ibekwe MU, Ibekwe RC, Umeora

MC, Okafor IO. Aetiology and

antibiotic sensitivity pattern of

ophthalmia neonatorum in Ebonyi

State University Teaching Hospi-

tal, Abakaliki, Niger J Paediatr

14. Olatunji FO. Ophthalmia neonato-

rum in Kaduna; a case control

study. Nig J Ophthalmol

20. Kolade ES. Ophthalmia neonato-

rum at University of Ilorin Teach-

ing Hospital, Ilorin. Dissertation

presented to the West African Col-

lege of Physicians, 1996.

21. Schober J. Therapic septischer

infecktionen bei fruh – und neuge-

borenen infektionen in der neona-

tologic; Franfurt 1987; 72-79.

22. Onile BA, Odugbemi T, Nwafor C.

Antibiotic susceptibility of Bacte-

rial agents of septicaemia in Ilorin,

Nigeria. Nig. Med Pract. 1985; 9

(4):93-96.

2003;11;2: 1.

15. Abdulkadir IA. Study of bacterial

agents of ophthalmia neonatorum

in Ahmadu Bello University

Teaching Hospital, Zaria; a Disser-

tation presented to National Post-

graduate Medical College of Nige-

ria, November 2008.

2

007; 34: 63

7

.

Iyamu E, Enabule O. Survey on

ophthalmia neonatorum in Benin

City, Nigeria (emphasis on gono-

coccal ophthalmia). Online J

Health Allied Scs 2003:2:1-6.

Ohara MA. Ophthalmia neonato-

rum. Paediatr Clin North Am

8

.

1

995; 40: 215 – 25