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Treatment recommendations

Based on consensus from the Children’s Mercy Infectious Disease Department, 2015 RedBook, and 2015 CDC STD treatment guidelines, those neonates perceived at risk for conjunctivitis due to Neisseria Gonorrhea, should also be considered high risk for systemic disease. It is recommend to obtain cultures of eye(s), blood, CSF, and other potential sites of infection and that these neonates be admitted to the hospital.

Acute care setting treatment and evaluation recommendations for neonatal conjunctivitis:

  • Ophthalmology consult and exam 

  • Antibiotic therapies:

    • Initial treatment: 

    • Ceftriaxone 25 to 50 mg/kg IV or IM x 1 (max 125 mg)

    • Ophthalmic irrigation as per Ophthalmology recommendation

    • Suspected systemic neonatal GC infection:

    • Ceftriaxone 25 to 50 mg/kg/day, IV or IM once daily for 7 days or

    • Cefotaxime 25 mg/kg every 12 hours daily for 7 days in the neonate with hyperbilirubinemia

    • Inpatient setting treatment and evaluation recommendations for neonatal conjunctivitis:

  • ID Consult

  • Ophthalmology consult and exam if not previously obtained in the acute care setting

  • Antibiotic therapies:

    • Initial treatment: 

    • Ceftriaxone 25 to 50 mg/kg IV or IM x 1 (max 125 mg)

    • Ophthalmic irrigation as per Ophthalmology recommendation

    • Suspected systemic neonatal GC infection:

    • Ceftriaxone 25 to 50 mg/kg/day, IV or IM once daily for 7 days or

    • Cefotaxime 25 mg/kg every 12 hours daily for 7 days in the neonate with hyperbilirubinemia

 

Neisseria Gonorrhea

Azithromycin 20 mg/kg/day x 3 days

Follow up options:

  • Ophthalmology Clinic referral (found in EDP: Eye Infection Powerplan--Neonatal Conjunctivitis Subphase)

Instruct parents to follow up with Primary Care Provider or Emergency Department if symptoms worsen

Chlamydia Trachomatis

 

Acute care setting treatment and evaluation recommendations for suspected HSV neonatal conjunctivitis:

  • Recommended culture and lab studies:

    • Viral culture from mouth, nasopharynx, anus, and conjunctivae 

    • Viral culture any skin vesicles

    • LP with cell counts, protein, glucose, culture, and HSV PCR

      Serum HSV PCR

    • AST, ALT

  • Initiate IV acyclovir 20 mg/kg/dose x1

  • Admit to hospital

Inpatient setting treatment and evaluation recommendations for suspected HSV neonatal conjunctivitis:

  • Recommended culture and lab studies if not previously obtained in the acute care setting:

    • Viral culture from mouth, nasopharynx, anus, and conjunctivae 

    • Viral culture any skin vesicles

    • LP with cell counts, protein, glucose, culture, and HSV PCR

    • Serum HSV PCR

    • AST, ALT

  • Inpatient ID consult

  • Inpatient Ophthalmology consult and exam if not previously consulted in the ED/acute care setting

  • Initiate IV acyclovir 20 mg/kg/dose q 8 hours

  • Suspected Neisseria Gonorrhea

 

Herpes Simplex Virus

Similar to infection with C. trachomatis, infection from N. Gonorrhea among neonates results from perinatal exposure to the mother’s infected cervix. Acute illness typically is seen between 2 and 5 days after birth and has been described clinically as “sudden, severe, grossly purulent conjunctivitis”. The prevalence of infection among infants depends on the prevalence of infection among pregnant women, whether pregnant women are screened and treated for gonorrhea, and whether newborns receive ophthalmia prophylaxis. The most severe manifestations of N. Gonorrhea infection in newborns are conjunctivitis and sepsis. Gonococcal sepsis in the neonate may also include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and infection at sites of fetal monitoring. 

Without adequate prophylaxis, an estimated 30 to 42% of infants vaginally born to infected mothers will develop gonococcal conjunctivitis. In Belgium, the overall prevalence of gonococcal conjunctivitis is very low (0.04 cases per 1000 live births) compared to the United States (0.3 cases per 1000 live births). N. Gonorrhea causes neonatal conjunctivitis relatively infrequently in the United States but identifying and treating this infection is important as it can result in perforation of the globe and blindness.

Gram stain showing white blood cells in the eye exudate should alert the provider to suspect infection from N. Gonorrhea, but non-gonococcal causes of neonatal conjunctivitis include Moraxella catarrhalis and other Neisseria species, which are indistinguishable from N. Gonorrhea, on grams stain, thus culture on proper media to select for N. Gonorrhea is mandatory and diagnosis cannot be made solely from gram stain results.

The gold standard for recovery of N. gonorrhea from an ocular specimen is culture. Currently the FDA approves NAA tests on endocervical swabs from women, urethral swabs from men, and urine from both men and women. Previous studies on neonates suspected of neonatal conjunctivitis due to N. gonorrhea have shown that PCR is equal or superior to culture from ocular specimens, however, these tests do not have FDA approval; therefore Children’s Mercy laboratory utilizes culture to identify N. gonorrhea. There are no new recommendations for recovery of N. gonorrhea other than culture and NAA/PCR tests are still not approved for eye surface use. 

Based on current literature the Care Process Model team recommends the use of culture for detection of N. gonorrhea in the neonate with suspected conjunctivitis.

 

Neisseria Gonorrhea


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. gonorrhea, C. 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, C., & Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 64(RR-03).

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.