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Swab affected eye(s) for Gonorrhea and Chlamydia cultures and HSV PCR

Rationale, current evidence, and consensus statement:

Studies have attempted to evaluate neonates presenting with symptoms of conjunctivitis to determine if clinical predictors exist to differentiate Chlamydia trachomatis (C. trachomatis) from Neisseria gonorrhea (N. gonorrhea).  One Hong Kong study that had 90 infants with conjunctivitis identified hemorrhagic eye discharge as a predictor for C. trachomatis with a reported 100% specificity and 100% positive predictive value.  No other studies have identified any clinical finding to predict a specific pathogen.  Rours and colleagues found that infants with C. trachomatis conjunctivitis compared to other infections were 2.3 times more likely to present at 1 to 6 weeks old, compared to the first week of life, and reported a relative risk of 1.5 (CI = 0.9 to 2.7) for C.trachomatis conjunctivitis when patients presented with mucopurulent discharge, eye swelling and eye redness.  However, Rours concludes that clinical predictors are not adequate to determine management options.  Some authors describe the typical presentation for both N. gonorrhea and C. trachomatis as N. gonorrhea occurring within the first 2 to 7 days after birth with C. trachomatis more likely occurring up to several weeks of life. However other studies have recommended caution for using patient age to determine clinical suspicion for a certain pathogen as cases of C. trachomatis have been reported in patients as young as 1 to 3 days of age.  Finally, some authors have looked at maternal risk factors to help determine a pathogen in neonatal conjunctivitis.  A correlation exists between the prevalence of maternal infections and rates of neonatal disease.  However, co-infection with other sexually transmitted pathogens is common and no clinical symptoms exist that distinguish the infecting pathogen.  The overall consensus is that providers will not be able to identify a pathogen on clinical grounds).  For Herpes Simplex Virus (HSV), isolated eye infection is rare.  Skin, Eye, and/or Mouth (SEM) disease should be suspected in the newborn/neonate born vaginally to a mother with a history or active infection with HSV.  Currently, there is no new medical literature regarding clinical features alone to predict N. gonorrheaC. trachomatis or HSV etiology of neonatal conjunctivitis.

Based on current literature the Care Process Model team recommends culture for C. trachomatis, N. gonorrhea, and HSV in neonates (< 28 days old) with conjunctivitis as described by purulent discharge or hemorrhagic discharge AND conjunctival injection/erythema.

References:

Chang, K., Cheng, V. Y., & Kwong, N. S. (2006). Neonatal haemorrhagic conjunctivitis: a specific sign of chlamydial infection. Hong Kong Med J, 12(1), 27-32.

MacDonald, N., Mailman, T., & Desai, S. (2008). Gonococcal infections in newborns and in adolescents. Adv Exp Med Biol, 609, 108-130. doi:10.1007/978-0-387-73960-1_9

O'Hara, M. A. (1993). Ophthalmia neonatorum. Pediatr Clin North Am, 40(4), 715-725.

Persson, K., & Ronnerstam, R. (1982). Neonatal eye infections caused by Chlamydia trachomatis. Scand J Infect Dis Suppl, 32, 141-145.

Rours, I. G., Hammerschlag, M. R., Ott, A., De Faber, T. J., Verbrugh, H. A., de Groot, R., & Verkooyen, R. P. (2008). Chlamydia trachomatis as a cause of neonatal conjunctivitis in Dutch infants. Pediatrics, 121(2), e321-326. doi:10.1542/peds.2007-0153

Workowski, K. A., Bolan, G. A., Centers for Disease Control & Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 64(RR-03).