Neonatal Conjunctivitis / Ophthalmia neonatorum

Neonatal Conjunctivitis

This is one of those conditions that can generate a lot of confusion and debate among intelligent people… and is therefore fun to think about.

Neonatal Conjunctivitis

  • As the name suggests, it is conjunctivitis that develops within the 1st 4 weeks of life.
  • Traditionally teachings about etiologies:
    • Chemical – day #1, mild conjunctivitis; less common now (less silver nitrate use)
    • GC – days #2-7, SEVERE conjunctivitis; can become disseminated (problem)!
    • Chlamydia – days 5-14, mild conjunctivitis; may lead to pneumonia
    • Other bugs/viruses – days 5-14, mild conjunctivitis; most prevalent

Unfortunately, nothing is that simple, and the concern for disseminated GC often leads to full sepsis work-ups.

  • The Red Book can be used to support this approach… and also a less aggressive approach.
  • If GC is suspected, “cultures of blood, eye discharge, or other sites of infection, such as CSF, should be performed…” and “Infants with gonococcal ophthalmia should be hospitalized and evaluated for disseminated infection (sepsis, arthritis, meningitis).”
  • Chlamydial infection, however, are much more common (GC accounts for <1% of neonatal conjunctivitis: even less disseminated complications of it).
  • Chlamydial infection is managed with ORAL antibiotics as an outpatient.

Where’s that leave us?

  • Well, here are two approaches that I think are justifiable.
  1. Do the full sepsis work-up. Rationalize that, in the ED, there is not a clinical way to determine whether you are dealing with GC and because of the potential concerns, cover all of your bases. This is the most conservative certainly.
  2. Send a blood culture and send a culture and PCR (for Chlamydia) of the ocular discharge. Send a gram stain of the ocular discharge and admit the child. If the Gram stain is suspicious for GC, then the decision to LP and start abx can be made.
    • The emergent administration of antibiotics is less of an issue and, as long as the child is doing well, this decision can be made in concert with the admission team.
  • With either plan, the most important therapy needs to be started; eye irrigation.

Ophthalmia neonatorum in Red Book.
Much appreciation to Dr. Amina Ahmed for her rational insight.


Sean M. Fox
Sean M. Fox
Articles: 583


  1. I am confused… Under Where’s that leaves us? in the first point (1) you mention do full septic work up (so also includes LP) but under (2) you mention do LP only if gram stain positive? Also, if I am doing full septic work up, why to defer abx, since gram stain is not perfect. You are right, this has cause lot of debate among lots of experts. Peds ID where I trained also wanted us to cover with very topical valacyclovir, because “thats in your differential..”

    • Dr. Patel,
      The (1) and (2) are not meant to be sequential steps, but rather option 1 and option 2. Since there is no consensus, local practice patterns will likely factor heavily into which option a practitioner will choose.
      Thank you,

  2. […] Peds ED.  We have entertained some considerations with respect to Conjunctivitis (especially in neonates), but occasionally, instead of seeing the “red eye” we were expecting, we see a child […]

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