In a setting where there are different levels of accessibility to health care, 
and where those people at most risk may well be those who coincidentally 
have least access to care, the only way to safeguard all babies against 
chlamydia infections in their eyes is to have prophylactic antibiotic instillation 
in newborns' eyes as the default.  As many of you have reported, one may 
sign a waiver of responsibility and simply decline the default treatment, and 
such a choice is defensible even if the parents don't know their STI status, as 
long as they observe the baby and get it treated if need be.

Chlamydia is very common in Europe, too, but I don't believe eye prophylaxis is 
practiced in most places; certainly it is not done in Scandinavia at all.  Our 
way of safeguarding babies' vision is to observe them for signs of infection, to 
culture when signs are observed, and treat appropriately as needed.  We see 
at least some clinical signs of conjunctivitis in fewer than ten percent of 
babies.  In practice, where I work, this means culturing those babies with 
really gunky eyes, and beginning treatment immediately thereafter with 
chloramphenicol eye drops if they look really bad.  If there isn't much stuff 
appearing, we try rinsing it away with sterile saline solution followed by 
instillation of mother's expressed milk every 3 to 4 hours, and if the symptoms 
are gone within a day or two we don't worry about it any more, meaning if it 
resolves with that treatment and we later get back a culture result showing 
staph, we shrug our shoulders and file the report in the medical chart.  In the 
20 years I have been in practice I've seen a handful of cases of neonatal 
conjunctivitis that cultured for something other than S. aureus.  Most of them 
were pseudomonas aeruginosa; none have been chlamydia or gonorrhea, 
despite virtually every one of these babies having been in contact with the 
genitals of a sexually active woman.

This approach only works if you have the chance to observe babies on at 
least a daily basis for the first few days of life.  Chlamydia and gonorrhea are 
not somehow accelerated in the newborn's eye, they are not galloping 
diseases like meningococcal septicemia; from the time of exposure (at passage 
through the birth canal of an infected woman) to the appearance of signs is a 
few days, and when signs appear, it takes days, if not weeks, to cause 
damage.  I suspect the reason for the rule about carrying out prophylaxis 
within one hour is so it won't get forgotten.

It would be fascinating to see whether the milk of women with chlamydia or 
gonorrhea contains antibodies specific for those organisms, so that their milk 
would be effective treatment even for conjunctivitis from those pathogens.  
We'd need some very convincing in vitro studies before anyone would do a 
human trial, though :-)

Rachel Myr
Kristiansand, Norway

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