Chlamydial Conjunctivitis

Chlamydial (inclusion) conjunctivitis is caused by Chlamydia trachomatis serovars D to K (genital serovars), distinct from trachoma serovars A to C.

• Adult inclusion conjunctivitis: sexually active young adults, from genital contamination (hands, shared water), swimming pools; often with genital infection (about half of cases asymptomatic).
• Neonatal inclusion conjunctivitis: transmission at birth (about 30 to 50 percent of exposed infants develop conjunctivitis).
• Obligate intracellular bacterium; chronic course if untreated, lasting months.

• Adults: unilateral or bilateral subacute red eye, mucopurulent discharge, foreign body sensation lasting more than 3 to 4 weeks despite topical antibiotics, with large follicles in the lower fornix, tender preauricular node.
• Corneal findings: punctate epithelial keratitis, marginal subepithelial infiltrates, micropannus (superior), rarely corneal scarring.
• Associated: urethritis, cervicitis, otitis media, and (with arthritis, uveitis, urethritis) reactive arthritis.
• Neonates: onset 5 to 14 days after birth, lid swelling, mucopurulent discharge, pseudomembrane, without follicles; risk of pneumonitis (afebrile, staccato cough, tachypnoea, at 4 to 12 weeks).

• Nucleic acid amplification test on conjunctival swab (most sensitive and specific); direct fluorescent antibody, Giemsa cytology (basophilic intracytoplasmic inclusions) historically.
• Genital testing of patient and partners (first void urine or swabs). Screen for gonorrhoea, syphilis, and HIV.
• Differentiate from adenoviral conjunctivitis (acute, watery) and trachoma (endemic, upper tarsal scarring).
• In neonates, nasopharyngeal specimen if respiratory symptoms.

• Adults: azithromycin 1 g orally single dose, or doxycycline 100 mg orally twice daily for 7 days (avoid in pregnancy). Alternatives: erythromycin 500 mg four times daily for 7 to 14 days, levofloxacin 500 mg daily for 7 days.
• In pregnancy: azithromycin 1 g single dose (or amoxicillin 500 mg three times daily for 7 days).
• Topical antibiotic (tetracycline 1 percent ointment or erythromycin 0.5 percent ointment four times daily for 3 to 4 weeks) is adjunctive; topical therapy alone is inadequate.
• Treat all sexual partners from the previous 60 days, and counsel abstinence until both treated for 7 days.
• Neonates: oral erythromycin base 50 mg/kg/day in 4 divided doses for 14 days, or azithromycin 20 mg/kg once daily for 3 days (repeat course if symptoms persist; monitor for pyloric stenosis in the first 6 weeks). Treat both parents.
• Test of cure for pregnant women 3 to 4 weeks after treatment, and retest at 3 months.
• Follow up for resolution of follicles, which may take several weeks.