Ophthalmia Neonatorum

Patient Population: Pediatric
Condition Major Pathogens  First-choice Therapy Alternative Therapy Comments

Ophthalmia neonatorum (eye infection at <30 days of age) 

Gonococcal ophthalmia usually manifests 2-5 days after birth with acute, severe conjunctivitis 

C. trachomatis ophthalmia usually manifests 5-12 days after birth with less severe conjunctivitis 

Either can present with discharge +/- conjunctival injection. If clinical concern in infant <30 days, at BCH the following tests should be obtained by swabbing everted eyelid: 

1. Chlamydia/Gonorrhea RNA NAAT (independently validated both BCH OAK and SF labs but not FDA-approved)


2. “Eye culture” (respiratory bacterial culture with Gram stain,  with comment to “look for N. gonorrhoeae”)  

Presumptive treatment (without a confirmed diagnosis) for N. gonorrhoeae is indicated for intracellular gram-negative diplococci on Gram stain, or high index of clinical suspicion pending cultures 

See guidance on HSV evaluation & management in neonates  

Chlamydia trachomatis 

Neisseria gonorrhoeae 

Consider HSV, other bacterial pathogens (per culture results), or noninfectious causes 

Proven or presumptive N. gonorrhoeae

Ceftriaxone 50 mg/kg/dose (max 125 mg/dose) IM/IV x 1 dose 

Refer to guidance addressing use of Ceftriaxone in neonates. Intravenous calcium-containing solutions should not be administered within 48 hours before or after Ceftriaxone administration 


Proven C trachomatis

20 mg/kg/dose enterally daily x 3 days* 



Management based on clinical characteristics, culture results as indicated 

Consult ID/ASP for alternative therapies if single dose of Ceftriaxone is contraindicated (for example due to administration of calcium-containing solutions) 

Topical therapy is not indicated for C. trachomatis or N. gonorrhoeae treatment - both require systemic therapy  

Infants with N. gonorrhoeae ophthalmia neonatorum require Ophthalmology consultation, admission for eye irrigation, and should be evaluated clinically for signs of disseminated infection (e.g., sepsis, arthritis, and/or meningitis) 

*Enteral Azithromycin recommended over Erythromycin given equivalent spectrum of activity with more convenient dosing and better side effect profile (decreased potential risk of QT prolongation and pyloric stenosis; fewer medication interactions) 

C. trachomatis ophthalmia neonatorum is generally self-limited, treatment is indicated to reduce risk of subsequent pneumonia or invasive disease 

Refer birth parent for evaluation as clinically indicated 


Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.  

Hammerschlag MR,  Gelling M,  Roblin PM,  Kutlin A,  Jule JE. Treatment of neonatal chlamydial conjunctivitis with azithromycin. Pediatr Infect Dis J, 1998; 17:1049-50. 

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.