AMERICAN COLLEGE OF PHYSICIANS - RPS Diagnostics

CLINICAL GUIDELINES

Conjunctivitis Testing

AMERICAN COLLEGE OF PHYSICIANS

Published in the Physicians Information and Education Resource (PIER) in 2013, which can be found online at . A thorough history and patient exam should be performed to identify the characteristic findings consistent with the diagnosis of viral conjunctivitis. Be aware that it is often difficult to differentiate viral from bacterial or allergic disease by the clinical exam. Clinical accuracy of about 40% to 70% compared to lab confirmation has been shown. A rapid, point-of-care immunoassay is available to detect Adenovirus. A prospective, masked clinical trial of a 10-minute in-office immunoassay for detecting Adenovirus conjunctivitis showed a sensitivity of 89% and a specificity of 94% compared to PCR, whereas viral cell culture showed a sensitivity of 91% and a specificity of 100%.1 Patients are recommended to remain out of school, work, or daycare for 5 to 7 days or until the eye is no longer red and tearing. Do not prescribe prophylactic antibiotics to prevent secondary bacterial infections in patients with known viral conjunctivitis.

UPTODATE?

An online, evidence-based clinical decision support system authored by physicians. Last updated October 16, 2012 available at . A rapid (10 minute) test for Adenoviral conjunctivitis is now available. Adenovirus is the major cause of viral conjunctivitis and likely accounts for a significant proportion of clinical encounters for conjunctivitis. This test has reasonable sensitivity and specificity under study conditions1 and might aid clinicians in determining a viral, as opposed to bacterial etiology, thereby avoiding empiric antibiotic therapy. Elimination of empiric antibiotic therapy has theoretical benefits including prescription drug savings, avoidance of side effects, and reduction of antibiotic resistance. A modeled cost effectiveness analysis suggests a potential for significant cost savings with point of care testing.2

CHOOSING WISELY?

Collaborative initiative among national medical specialty organizations to promote conversations between providers and patients to choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary. The American Academy of Ophthalmology (AAO) recommends not ordering antibiotics for Adenoviral conjunctivitis (pink eye). The Choosing Wisely recommendations from AAO can be found online at american-academy-of-ophthalmology/.

CLINICAL GUIDELINES

Conjunctivitis Testing

Adenoviral conjunctivitis and bacterial conjunctivitis are different forms of infection that can be diagnosed by the ophthalmologist by clinical signs and symptoms, and if needed, by cultures. Antibiotics are useful for patients with bacterial conjunctivitis, particularly those with moderate to severe bacterial conjunctivitis. However, they are not useful for Adenoviral conjunctivitis, and the overuse of antibiotics can lead to the emergence of bacteria that don't respond readily to available treatments. In cases of diagnostic uncertainty, patients may be followed closely to see if their condition resolves on its own, or if further treatment is required.

AMERICAN ACADEMY OF PEDIATRICS

Published in The Red Book in 2012, which can be accessed online at . The preferred practice methods for diagnosis of Adenovirus infection include cell culture as well as antigen and DNA detection. Adenoviruses associated with respiratory tract disease can be isolated from pharyngeal and eye secretions and feces by inoculation of specimens into susceptible cell cultures. A pharyngeal or ocular isolate is more suggestive of recent infection than is a fecal isolate, which may indicate prolonged carriage or recent infection. Adenovirus antigens can be detected in less than 30 minutes in a variety of body fluids from infected people by commercial immunoassay techniques. These rapid assays especially are useful for diagnosis of diarrheal disease, because enteric Adenovirus types 40 and 41 usually cannot be isolated in standard cell cultures, and for ocular disease. Treatment of Adenovirus infection is supportive.

AMERICAN ACADEMY OF OPHTHALMOLOGY

Published in the Conjunctivitis Preferred Practice Pattern in 2013, which can be accessed online at . Some cases of conjunctivitis can be diagnosed on the basis of history and examination (e.g., viral conjunctivitis in the presence of an upper respiratory infection). In other cases, however, additional diagnostic tests may be helpful. Viral cultures are not routinely used to establish a diagnosis. A rapid, in-office immunodiagnostic test using antigen detection is available for Adenovirus conjunctivitis. In a study of 186 patients with acute conjunctivitis, this test had a sensitivity of 88% to 89% and a specificity of 91% to 94%.1 More recently, a study of 128 patients with acute viral conjunctivitis found that a newer test had a sensitivity between 85% and 93% and a specificity between 96% and 99%.3 Immunodiagnostic tests may be available for other viruses, but these are not validated for ocular specimens.

References [1] Sambursky R, Tauber S, Schirra F, et al. The RPS adeno detector for diagnosing Adenoviral conjunctivitis. Ophthalmology 2006;113:1758-64 [2] Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for Adenoviral conjunctivitis. Am J Med Sci 2008;336:254. [3] Sambursky R, Trattler W, Tauber S, et al. Sensitivity and specificity of the AdenoPlus test for diagnosing Adenoviral conjunctivitis. JAMA Ophthalmol 2013;131:17-21

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