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Class: Anti-infectives, Miscellaneous
ATC Class: S01AX02
CAS Number: 7761-88-8
Anti-infective; astringent and caustic agent.a
Uses for Silver Nitrate
Prophylaxis in Gonococcal Ophthalmia Neonatorum
Prophylaxis of gonococcal ophthalmia neonatorum.a b AAP recommends topical prophylaxis in all neonates, regardless of delivery route (i.e., vaginal or cesarean section) shortly after birth; prophylaxis required by law in most states.117 118 b c
AAP recommends use of topical silver nitrate, topical erythromycin, or topical tetracycline (no longer commercially available as a single-entity preparation in the US) for prophylaxis of gonococcal ophthalmia neonatorum.118 b
AAP states that topical silver nitrate is the preferred agent for the prevention of gonococcal ophthalmia neonatorum in areas where the incidence of penicillinase-producing Neisseria gonorrhoeae (PPNG) is relatively high.118 b
CDC previously recommended use of topical silver nitrate for prophylaxis of gonococcal ophthalmia neonatorum; however, CDC now recommends only topical erythromycin or topical tetracycline (no longer commercially available as a single-entity preparation in the US).117 c
Infants born to women with untreated gonorrhea should receive systemic prophylaxis (e.g., ceftriaxone).b c If gonococcal ophthalmia is diagnosed, systemic therapy (e.g., ceftriaxone) is necessary.116 117 c
Prophylaxis of Chlamydial Ophthalmic Infections
Efficacy not established in the prevention of chlamydial neonatal conjunctivitis†.101 102 103 104 106 107 109 114 116 118 119 c
AAP and CDC state that topical prophylaxis with silver nitrate, erythromycin, or tetracycline does not prevent perinatal transmission of Chlamydial trachomatis† from mother to infant.101 102 104 109 114 115 117 118 119 b c
Prophylaxis in Nongonococcal Nonchlamydial Ophthalmia
AAP recommends use of topical silver nitrate, povidone-iodine, or possibly erythromycin for prophylaxis of nongonococcal nonchlamydial conjunctivitis in neonates, ideally administered shortly after birth.b
Silver Nitrate Dosage and Administration
Silver nitrate 1% ophthalmic solution is no longer commercially available in the US.a
Apply topically to the eyes as an ophthalmic solution.a b Do not use solution when cold.a Avoid contact with skin, mucous membranes, and other surfaces.a (See Topical Irritation under Cautions.)
Administer solution to neonate shortly after delivery;117 118 b delaying prophylaxis for ≤1 hour after delivery to facilitate parent-infant bonding is unlikely to affect efficacy.118 b
Initially, clean eyes of the neonate using sterile gauze or cotton and sterile water.a b Use a separate pledget for each eye and the eyelids (without opening); wash from the nose outward until free of all blood, mucus, or meconium.a
Following cleaning, open the eyelids.a Instill solution into lower conjunctival sacs (at the angle of the nasal bridge and eyes).a b Ensure that eyelids are separated and elevated from the eyeball to allow solution to contact the entire conjunctival sac and eye for ≥30 seconds.a
Wipe away excess solution around the eye after 1 minute.a b Remove excess solution on the skin around the eye to prevent staining.a
Do not irrigate eyes following application.118 a b (See Ophthalmic Effects and also see Chemical Conjunctivitis under Cautions.)
Prophylaxis of Gonococcal Ophthalmia Neonatorum
Neonates: Following cleaning, instill 2 drops of a 1% solution.a b
Prophylaxis of Nongonococcal Nonchlamydial Ophthalmia
Neonates: Following cleaning, instill 2 drops of a 1% solution.b
No special population dosage recommendations at this time.a
Cautions for Silver Nitrate
Repeated applications may cause corneal cauterization and blindness.a
Severe ocular injury including permanent corneal opacification and cataracts reported after mistaken or accidental single-dose administration of 5–50% silver nitrate solutions.a Ophthalmic administration of solutions >1% concentration not currently recommended.a
If a silver nitrate ophthalmic solution >1% concentration is applied, irrigate immediately with sterile water or 0.9% sodium chloride.a
AAP does not currently recommend irrigation of eyes following application of 1% solution.118 b Irrigation may reduce the efficacy of prophylaxis without reducing the incidence of chemical conjunctivitis.118 b (See Administration under Dosage and Administration and see Chemical Conjunctivitis under Cautions.)
Mild chemical conjunctivitis occurs in up to 90% of neonates within 6 hours after application; however, rarely persists >24 hours.a (See Ophthalmic Effects under Cautions.)
Avoid contact with skin or other surfaces; may stain skin and may be caustic and irritating to skin and mucous membranes.a Typically, skin staining slowly disappears spontaneously; however, may persist indefinitely at some sites.a
Common Adverse Effects
Mild chemical conjunctivitis.a
Interactions for Silver Nitrate
No formal drug interaction studies to date.a
Silver Nitrate Pharmacokinetics
Not readily absorbed from mucous membranes following topical administration; does not readily penetrate into tissues.a
Store in inert, collapsible (or other suitable single-dose) containers at 15–30°C.a Protect from light; do not freeze.a Do not use solution when cold.a
For information on systemic interactions resulting from concomitant use, see Interactions.
Ophthalmic Topical Solution
Reportedly incompatible with thimerosal, benzalkonium chloride, halogenated acids and their salts, alkalis, and phosphates.a
Antiseptic, germicidal, astringent, and caustic or escharotic activity.a
Activity may result from silver ions combining with sulfhydryl, carboxyl, phosphate, amino, and other biologically important chemical groups.a May alter physical properties of proteins; denaturation and precipitation may occur.a
Germicidal activity may be attributed to precipitation of bacterial proteins by liberated silver ions.a
Extent of activity depends on concentration and duration of time compound acts.a At lower concentrations, precipitation prevents deep tissue penetration and astringent action occurs.a At high concentrations, membrane and intracellular structures are damaged and caustic or escharotic action occurs.a
Advice to Patients
Advise patients that most skin staining disappears slowly over time; however, some staining may persist indefinitely.a
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.a
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast feed.a
Importance of informing patients of other precautionary information. (See Cautions.)
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS DI Essentials. © Copyright 2017, Selected Revisions June 1, 2008. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
Only references cited for selected revisions after 1984 are available electronically.
101. Anon. Neonatal gonococcal ophthalmia—California. MMWR Morb Mortal Wkly Rep. 1983; 32:518-9. [PubMed 6412066]
102. Zola EM. Evaluation of drugs used in the prophylaxis of neonatal conjunctivitis. Drug Intell Clin Pharm. 1984; 18:692-6. [PubMed 6383753]
103. Hammerschlag MR, Chandler JW, Alexander ER et al. Erythromycin ointment for ocular prophylaxis of neonatal chlamydial infection. JAMA. 1980; 244:2291-3. [PubMed 7431552]
104. Rettig PJ, Patamasucon P, Siegel JD. Postnatal prophylaxis of chlamydial conjunctivitis. JAMA. 1981; 246: 2321-2. [PubMed 7299949]
106. Dillon HC Jr. Prevention of gonococcal ophthalmia neonatorum. N Engl J Med. 1986; 315:1414-5. [PubMed 3773967]
107. Sandstrom I. Ophthalmia neonatorum with special reference to Chlamydia trachomatis: diagnosis and treatment. Acta Paediatr Scand. (Suppl). 1986; 330:1-27. [PubMed 3107338]
109. Hammerschlag MR. Neonatal ocular prophylaxis. Pediatr Infect Dis J. 1988; 7:81-2. [PubMed 3344174]
114. Fransen L, Klauss V. Neonatal ophthalmia in the developing world: epidemiology, etiology, management and control. Int Ophthalmol. 1988; 11:189-96. [PubMed 3047073]
115. Laga M, Plummer FA, Piot P et al. Prophylaxis of gonococcal and chlamydial ophthalmia neonatorum: a comparison of silver nitrate and tetracycline. N Engl J Med. 1988; 318:653-7. [PubMed 3278234]
116. Bell TA, Sandstrom KI, Gravett MG et al. Comparison of ophthalmic silver nitrate solution and erythromycin ointment for prevention of natally acquired Chlamydia trachomatis. Sex Transm Dis. 1987; 14:195-200. [PubMed 3438783]
117. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Morb Mortal Wkly Rep. 2002; 51(No. RR-6):1-80.
118. Committee on Infectious Diseases, American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000:208-12,735,741.
119. Hammerschlag MR, Cummings C, Roblin PM et al. Efficacy of neonatal ocular prophylaxis for the prevention of chlamydial and gonococcal conjunctivitis. N Engl J Med. 1989; 320:769-72. [PubMed 2922026]
a. AHFS drug information 2008. McEvoy GK, ed. Silver nitrate. Bethesda, MD: American Society of Health-System Pharmacists; 2008. Updated 2004 Jan 01. Available at: .
b. American Academy of Pediatrics. Red Book Online. Elk Grove, IL: American Academy of Pediatrics. Available at: . Accessed 2007 June 18.
c. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006; 55:(No. RR-11):1-94.