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Swab Affected Eye(s) For Gonorrhea, HSV, and Chlamydia

Rationale, current evidence, and consensus statement:

Currently, there is no new medical literature regarding clinical features alone to predict N. gonorrhoeae, C. trachomatis or herpes simplex virus (HSV) etiology of neonatal conjunctivitis. The Care Process Model team recommends PCR for C. trachomatis, N. gonorrhoeae, and HSV, and culture for N. gonorrhoeae in neonates (≤ 28 days old) with conjunctivitis as described by purulent discharge or hemorrhagic discharge AND conjunctival injection/erythema.

Studies have attempted to evaluate neonates presenting with symptoms of conjunctivitis to determine if clinical predictors exist to differentiate C. trachomatis from N. gonorrhoeae. One study from Hong Kong (Chang et al., 2006) included 90 infants with conjunctivitis and 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 et al. (2008) 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, 95% CI [0.9, 2.7] for C. trachomatis conjunctivitis when patients presented with mucopurulent discharge, eye swelling, and eye redness.  However, the study by Rours et al. concludes that clinical predictors are not adequate to determine management options. 

Some authors describe the typical presentation for both N. gonorrhoeae and C. trachomatis as N. gonorrhoeae 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 consensus is that providers will not be able to identify a pathogen on clinical grounds. 

Isolated eye infection with HSV 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.  


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).

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.