Chlamydia Trachomatis
Among infants bom to untreated mothers with Chlamydia trachomafis infections, the overall risk of disease is estimated at 50 to 75% and typically involves the mucous membranes of the eye, oropharynx, urogenital tract, and rectum. Conjunctivitis, which typically develops between 5 and 12 days after birth, is the most frequently recognized manifestation of C. trachomatis infection, and among neonates with exposure to chlamydia, it occurs in an estimated at 30 to 50% Countries with higher rates of maternal C. trachomafis infection estimate as many as 15-18 cases per 1000 live births while countries with less prevalent disease estimate as low as 4 cases per 1000 live births. Recent epidemiologic studies in the US are lacking, however previous data estimates 8.2 cases of C. trachomitis conjunctivitis per 1000 United States live births. While most cases of chlamydial conjunctivitis self-resolve without complications, there is a risk of superficial corneal vascularization and conjunctival scarring if left untreated. Traditionally treatment with a 14 days course of erythromycin was recommended, however treatment considerations now include a short course of oral azithromycin.
The gold standard for recovery of C. trachomatis 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 ophthalmia neonatorium have shown that PCR is equal or superior to culture from ocular specimens, however, these tests did not obtain FDA approval; therefore Children's Mercy laboratory utilizes culture to identify C. trachomatis. Also note that since C. trachomatis is an obligate intracellular organism, culture specimens must contain epithelial cells. There are no new recommendations for recovay of C. trachomatis other than culture as NAA 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 C. trachomatis in the neonate with suspected conjunctivitis.
Rationale, current evidence, and consensus statement
While most cases of chlamydial conjunctivitis self-resolve without complications, there is a risk of superficial comeal vascularization and conjunctival scarring if left untreated. C. trachomatis also can cause a sub-acute, afebrile pneumonia with onset at ages 1 to 3 months. Traditionally treatment a 14 days course of erythromycin was recommended, however treatment considerations now include a short course of oral azithromycin. Excluding concerns for social or treatment compliance concems, most neonates can be managed in the outpatient setting with follow-up with their primary care provider or Ophthalmology in 24 to 72, while awaiting eye culture results.
References
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Committee on Infectious Diseases. (2015). Red Book: Report of the Commitee on Infectious Diseases (2015) (Kimberlin Brady, MT, Jackson MA, & Long, SS Eds. 30 ed.): American Academy of Pediatrics
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These pathways 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 a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.