Ophthalmia Neonatorum Research Articles

Are Chlamydia Trachomatis and Neisseria Gonorrhoeae Screenings in Pregnant Women Being Properly Performed? A Single-Center Retrospective Observational Study in Italy.

A new Italian intersociety position statement on the prevention of ophthalmia neonatorum was published in 2023. In this document, attention was paid to the indications for the screening of gonococcal and chlamydial infections during pregnancy according to the international and national guidelines for the prevention of sexually transmitted infections (STIs). We conducted an observational retrospective study to assess whether the current guidelines for the prevention of STIs are being followed correctly. From February to August 2022, 2507 women nearing childbirth were enrolled. Among them, 42.4% received a swab for Chlamydia and only 0.5% for gonococcus. Concerning the geographical area of origin, most of the screened women came from Western Europe. None of the women who received gonococcal swabs and only 105 women out of 1062 screened for Chlamydia were under 25 years of age. Overall, only seven swabs were positive for Chlamydia, while none were positive for gonococcus. Concerning the age, geographical area of origin, and medical history of the women with a positive screening for Chlamydia, all were over 25 years old, six were from Western Europe, one was from South America, and none had other STIs. Although monocentric in nature, this study shows that the guidelines are not being followed correctly.

Current alternative therapies for treating drug-resistant Neisseria gonorrhoeae causing ophthalmia neonatorum.

Ophthalmia neonatorum is a microbial contraction, damaging eyesight, occurring largely among neonates. Infants are particularly vulnerable to bacterial infections acquired during birth from infected mothers, especially from Neisseria gonorrhoeae and Chlamydia trachomatis. Over the decades, N. gonorrhoeae is alarmingly developing a resistance to most antibiotics currently prescribed. To counter this challenge, it is imperative to find potent and cost-effective therapeutic agents for prophylaxis and treatment, to which the N. gonorrhoeae cannot easily develop resistance. This review showcases alternate therapies such as antimicrobial-fatty acids, -peptides, -nano-formulations etc., currently evident against N. gonorrhoeae-mediated ophthalmia neonatorum, which remains a major cause of ocular morbidity, blindnessand even death among neonates in developing countries.

Intersociety Position Statement on the Prevention of Ophthalmia Neonatorum in Italy.

There is currently no worldwide agreement on the real need to administer conjunctival antibiotics to neonates at birth to prevent neonatal conjunctivitis (usually defined as ophthalmia neonatorum) by Chlamydia trachomatis and Neisseria gonorrhoeae. Therefore, there is wide variability in antibiotic administration, conditioned mainly by the social and health context. In Italy, a law enacted in 1940 required doctors and midwives to administer ophthalmic prophylaxis with 2% silver nitrate to all newborns at birth. This law was repealed in 1975 and since then there has been no clear guidance on the use of ophthalmia neonatorum prophylaxis at birth. Since neonatal conjunctivitis caused by C. trachomatis and N. gonorrhoeae is not reported, we carried out a nationwide survey of 1,041,384 neonates across all Italian birth centers to evaluate the incidence of ophthalmia neonatorum and the current practice of prophylaxis. After analyzing the results, we formulated an intersociety position statement on the prevention of ophthalmia neonatorum to update and standardize this prevention strategy in Italy.

Congenital herpes simplex with ophthalmic and multisystem features: a case report

BackgroundNeonatal herpes simplex virus (HSV) infection is rare and has significant morbimortality rates. Approximately 85% of newborns are infected intrapartum, and risk factors for mother-to-child transmission include vaginal delivery, primary maternal infection, and prolonged rupture of membranes. Neonatal HSV can manifest with isolated mucocutaneous lesions, neurological involvement, or disseminated disease. In general, herpetic infection can cause blepharoconjunctivitis or keratitis. We report a rare case of congenital herpes with ophthalmologic manifestations and multisystemic involvement.Case presentationA preterm infant, born at 32 weeks and 2 days, with presumed neonatal infection developed intestinal and respiratory complications, as well as hyperemic lesions on the left nostril and oral mucosa. An ophthalmological assessment was requested and brought up the suspicion of HSV infection, indicating empirical treatment with endovenous acyclovir. Later, a new ocular examination was suggestive of panuveitis. Afterward, serum IgM antibodies to HSV-1 and HSV-2 were positive. Proper antiviral therapy led to an improvement in the condition.DiscussionNeonatal herpes is associated with a high risk of persistent skin lesions, long-term neurological disability and other lasting sequelae. It is essential to consider HSV infection in cases of neonatal conjunctivitis, especially in patients with an epithelial defect and no improvement after initial treatment with topical or systemic antibiotics.ConclusionsIn the management of neonatal HSV, early diagnosis is essential for the timely initiation of antiviral therapy. Our report highlights that ocular assessment can be crucial in the correct diagnostic investigation of this condition.

A Critical Review On the Management of Kukunaka with Special Reference to Neonatal Conjunctivitis

In Ksheerapa avastha, kukunaka is a specific inflammatory eye illness that most commonly affects infants under eight months.Kukunaka is mentioned as Vartmagata Kapha-Raktaj disease of eye. It is a Bala Netrarog linked to photophobia and ocular weakening.The most prevalent eye condition affecting infants is kukunaka, associated with neonatal conjunctivitis or Ophthalmia neonatorum.Local irritation, microorganisms, and the herpes simplex virus are the main causes of inflammation. It happens due to postpartumdifficulties or infections and maternal infections during labor and delivery. Because of an allergic reaction, the child keeps rubbing theirforehead, eyes, nose, and throat. This condition is characterized by watering and purulent discharge from both eyes and keratitis oruveitis may also be present. A neonate with neonatal conjunctivitis or ophthalmia neonatorum would have an inflamed conjunctiva.This review paper aims to review the management of Kukunaka from classical texts of Ayurveda. This review was conducted by learningAyurveda classical texts related to Kaumarbhrutya, Pediatrics texts on Neonatal diseases, published research journals on Pediatricdiseases, and electronic databases. This review's peculiarity is compiling all the data for kukunaka vyadhi from classic texts like its clinicalfeatures, causative factors, and various internal and external medications. Various formulations of kukunaka that are not studied yet areenlightened in this review, along with some shodhana karma that was indicated to nursing mothers and infants, are described in detail.The article concludes that this review is carried out for future research, which will be helpful for the management of kukunaka.

Is Ophthalmia Neonatorum Associated With Invasive Bacterial Infection? A Single-Center Retrospective Study.

Ophthalmia neonatorum (ON) is a conjunctivitis occurring in neonates and can be caused by multiple bacterial pathogens. The risk of invasive bacterial infection (IBI) in neonates with ON is poorly known. Our objectives were to document the association of ON with IBI in term neonates and to investigate practice variation. This was a retrospective observational study of all neonates who presented to a single emergency department (ED) between January 2018 and December 2019. Participants were all children with a final diagnosis of ON according to the treating physician as registered in the ED computerized database. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management, and treatment plan) as well as complications (ocular morbidity, death, and unscheduled return visits) were collected. Data were analyzed using descriptive statistics. Fifty-two term neonates were included. There were no cases of IBI associated with ON (0%; 95% confidence interval [CI], 0%-6.9%). Six ocular bacterial infections were identified, one of which was Chlamydia trachomatis. Although there were no IBIs, ocular complications, deaths, or unscheduled return visits to the ED, there was a wide variation in physician's management of ON. Physicians ordered investigations in 49% (95% CI, 34%-62%) of neonates, prescribed antibiotics to 87% (95% CI, 74%-94%), and involved specialists in 39% (95% CI, 27%-52%) of cases. Emergency department presentations of term neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of neonates with ON presenting to the ED.

Sexually Transmitted Infections and HIV in Ophthalmology.

The ocular and periocular manifestations of sexually transmitted infections (STIs) are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with STIs resulting in eye disease.

Gellan gum and sodium alginate in-situ gel of monocaprin for effective corneal permeation

Babies born to mothers suffering from gonorrhea may experience severe eye infections that might culminate in loss of vision. The eyes of the neonate can are infected with Neisseria gonorrhoeae, during birth. The primary goal of the study was to develop a stable aqueous ion-activated polymeric solution with clinically useful amounts of fatty acid-based monocaprin and a polymeric mixture of two commonly employed edible polysaccharide, sodium alginate and gellan gum. Monocaprin is an antibacterial agent against the treatment of gonococcal ophthalmia neonatorum, which was successfully formulated as an ion-activated in-situ gel-forming ophthalmic solution. The absence of drug-polymer interaction was confirmed from the FTIR study. The gelling capacity confirmed pH dependent (pH 7.2–7.4) sol-to-gel transition at 37°C±0.5°C. Formulation C4 was selected as the best formulation because it exhibited clear appearance, pH, good gelling capacity, optimum viscosity, 96.4% in-vitro drug release up to 11h. Formulation C4 also exhibited 96.6% drug release after 12h using goat cornea. The study results demonstrated remarkable enhancement in corneal permeation of in-situ gel in contrast to conventional eye drops. Sterility results showed no evidence of bacterial growth after 14 days in different media. The developed monocaprin incorporated sodium alginate and gellan gum based in situ gel formulation showed promising results with increased ocular residence and enhanced corneal permeability.

Antibiotic prophylaxis for ophthalmia neonatorum in Italy: results from a national survey and the Italian intersociety new position statements

BackgroundOphthalmia neonatorum is an acute conjunctivitis that occurs in newborns within the first month of life. The most serious infections are due to Chlamydia trachomatis and Neisseria gonorrhoeae, that may cause permanent damages. The use of ophthalmic prophylaxis varies widely around the world, according to the different health and socio-economic contexts. To date in Italy there is no a clear legislation regarding ophthalmia neonatorum prophylaxis at birth.MethodsWe invited all birth centers in Italy to carry out a retrospective survey relating the last three years. We collected data regarding demographics of neonates, drugs used for ophthalmic prophylaxis and results of the screening of pregnant women for Chlamydia trachomatis and Neisseria gonorrhoeae vaginal infections.ResultsAmong 419 birth centers, 302 (72,1%) responded to the survey. Overall 1041384 neonates, 82,3% of those born in the three years considered, received ophthalmic prophylaxis. Only 4,585 (0,4%) of them received one of the drugs recommended by the WHO. The Centers that participated to the survey reported 12 episodes of Chlamydial conjunctivitis and no Gonococcal infection in the three years. Only 38% of the Centers performed vaginal swabs to pregnant women: 2,6% screened only for Neisseria, 9,6% only for Chlamydia and 25,8% for both germs.ConclusionsThe data obtained from the survey showed a low incidence of neonatal conjunctivitis due to either Neisseria gonorrhoeae or Chlamydia trachomatis in Italy. Due to the lack of legislation regulating the prophylaxis of ophthalmia neonatorum in newborns, the Italian Society of Neonatology, the Italian Society of Obstetrics and Gynecology and the Italian Society of Perinatal Medicine have recently issued new recommendations on this topic.

Sexually transmitted infections and HIV in ophthalmology

The ocular and periocular manifestations of sexually transmitted infections are heterogeneous in etiology, manifestations, and complications. Etiologic agents include bacteria, viruses, parasites, and protozoa, which are most frequently transmitted via direct ocular contact with an active lesion or infected bodily fluid, autoinoculation, or dissemination from a distant site. Vertical transmission most commonly occurs perinatally during vaginal delivery. The complications of ophthalmia neonatorum can be severe, with the potential for permanent blindness or life-threatening systemic involvement if untreated. Clinical features, diagnostic modalities, and therapeutic regimens vary based on etiology and are summarized in this review. Prompt diagnosis is imperative, given the severe sequelae that may result from ocular involvement in these infections, including permanent vision loss. A multidisciplinary approach, involving both ophthalmology and dermatology, to diagnosis and management is essential to mitigate the risk of morbidity associated with sexually transmitted infections resulting in eye disease.

Ophthalmia Neonatorum, Helen Keller, and the Social Dimensions of Eye Disease.

The aim of this study was to describe how an early 20th-century American celebrity attempted to influence public perception of ophthalmic neonatorum. This study reviews the editorial written by Helen Keller in the 1909 Ladies' Home Journal and related historical documents about the prevention of blindness from neonatal conjunctivitis. Although blind, deaf, and nulliparous, Helen Keller at the age of 29 sensed that the newborn children of many American women were being denied preventative treatment for ophthalmia neonatorum. In her editorial in the Ladies' Home Journal discussing the complications of venereal disease she urged women to become proactive in matters of personal and family health care. Helen Keller viewed blindness from ophthalmia neonatorum as a failure of the American health care system. Her solution was to impart women with enough knowledge to seek care from educated medical professionals. The observation that many women and their children were receiving substandard care reflected a fundamental problem with disparities in the delivery of perinatal health care. Her insights are as relevant today as they were in 1909.

Benjamin Gibson 1774-1812: Manchester's first ophthalmologist.

Benjamin Gibson, a Newcastle-born surgeon, trained in Lancaster, Chester, London and Edinburgh before being appointed as assistant to Charles White, Manchester surgeon and man-midwife. He developed expertise in eye diseases, particularly of children. In 1804 he was appointed Honorary Surgeon to the Manchester Infirmary. He died young in 1812, but had published significantly on the cause of ophthalmia neonatorum, on cataract surgery in infants (the first to do so) and on surgery to reform damaged pupils. He was the first specialist oculist in Manchester and the North of England, and the first in that region to perform cataract extraction.

A review of clinical practice guidelines for preventing chlamydial and gonococcal ophthalmia neonatorum

Abstract Objective: The objective of this study is to evaluate and analyze clinical practice guidelines pertinent to the prevention of ophthalmia neonatorum in newborns after delivery. The aim is to offer guidance to medical and nursing staff regarding newborn eye care within the clinical context. Methods: WHO, Guidelines International Network, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, Queensland Clinical Guideline, Joanna Briggs Institute, Canada Registered Nurses’ Association of Ontario, New Zealand Guidelines Group, and Chinese Medlive, professional societies focusing on newborn care, and bibliographic databases, such as PubMed, Embase, Web of Science, CNKI, WanFang Database, VIP, and SinoMed, were systematically searched. The International Guidelines Evaluation Screening Tool and Appraising Guidelines Research and Evaluation II were utilized to assess the quality of the guidelines. Content analysis methodology was used for summarization, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to determine the quality of evidence and the strength of recommendations. Results: A total of 8 guidelines pertaining to neonatal ophthalmia were included in the analysis. Among them, guidelines from the National Institute for Health and Clinical Excellence and WHO obtained higher scores (≥80%). Seven guidelines recommended universal topical ocular prophylaxis. In addition, 2 guidelines recommended prescreening and pretreatment of pregnant women at risk of exposure to chlamydia and gonococcus. In total, 17 recommendations were summarized. While the quality of specific evidence ranged from “very low” to “low,” the majority (12/17) of the recommendation strengths were classified as “strong.” Conclusions: In the clinical context, both universal topical ocular prophylaxis for neonates and screening and treatment of pregnant women and their partners for sexually transmitted diseases are recommended.

Regional Institute of Ophthalmology and Government Ophthalmic Hospital: The Heart of Heritage

Regional Institute of Ophthalmology and Government Ophthalmic Hospital: The Heart of Heritage

Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management.

Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.

Effects of prenatal antibiotic treatment on early infant health: a retrospective study in a rural health facility in Ghana.

Infant mortality remains a major developmental challenge in many low-income countries. Epidemiological evidence suggests that infant acquisition of maternal microbiome is essential for programming of immunity and metabolism. As such, irrational maternal antibiotic use may affect infant health. The aim of the study was to determine the effects of prenatal antibiotic use on early postnatal life (90 days) in a low-income community in Ghana. The study was a retrospective study of 412 mother-baby pair medical records in a low-income community in rural Ghana. During the ninety-day period, the prevalence and relative risk of neonatal sepsis, respiratory disorders, and dermatitis were significantly higher in infants treated prenatally with antibiotics compared to untreated infants. Prenatal antibiotic treatment was not significantly associated with the risk of developing neonatal jaundice and conjunctivitis. However, prenatally antibiotic exposed infants were three times likely to visit the hospital for a non-scheduled/non-review treatment within the first 90 days compared to unexposed babies. Intrapartum antibiotic treatment is associated with poor early infant health. Rationalizing antibiotic use during pregnancy may contribute to reducing infant mortality.

Effect of the Clinical Usage of Tetracaine Hydrochloride Ophthalmic Solution on Multiple Antibiotic Resistant Staphylococcus Aureus

Background: The emergence of resistant strain bacteria is rendering many antibiotics ineffective in the management of infectious diseases.
 Objective: The purpose was to investigate the effect of Tetracaine hydrochloride usage on the emergence of a resistant strain of bacteria.
 Materials and methods: A total of fifteen New Zealand White rabbits of either sex weighing between 1400-2700 grams were used for this study. Infectious agents of Ophthalmia neonatorum were cultured, isolated and identified. Their susceptibility to various antibiotics was assessed. A resistant strain was picked up and inoculated on the conjunctiva of the rabbits to induce bacterial conjunctivitis. Rabbits were divided into three groups of five rabbits each. Group A received Tetracaine as treatment, group B received 0.3% Ciprofloxacin as treatment and group C received normal saline as a treatment for 14 days. Outcome measures included bacterial colony count, clinical signs and post-antibiotic susceptibility test.
 Results: The tetracaine significantly reduced clinical signs (P=0.012) compared to normal saline (control) and 0.3% Ciprofloxacin reduced clinical signs (P =0.003) compared to normal saline (control). This means there was a significant decrease in clinical scores with the interventions as compared to the normal saline which showed minimal change in clinical score. Tetracaine hydrochloride significantly reduced bacteria load (P≤0.0001). It decreased multiple antibiotic-resistant index by 20%.
 Conclusion: Tetracaine has a supplemental antibiotic effect on resistant strain of bacteria and does not worsen antibiotic resistance of bacteria. Clinical usage of tetracaine ophthalmic solution should therefore be applied after conjunctival swaps or corneal scrapping have been taken.

Universal ophthalmia neonatorum prophylaxis in Ontario: a cost-effectiveness analysis.

Although prophylaxis for ophthalmia neonatorum at birth is required by law in Ontario, declining prevalence of disease and efficacy of prophylaxis have called this practice into question. The objective of this modelling study was to assess the cost-effectiveness of universal prophylaxis for ophthalmia neonatorum to inform decision-makers on the potential impact of a change in this policy. We compared the cost-effectiveness of prophylaxis for ophthalmia neonatorum with no prophylaxis through cost-utility analysis with a lifetime time horizon, considering a provincial government payer, for a hypothetical population of newborns in Ontario. We assessed both the mean incremental costs of prophylaxis and its mean incremental effectiveness using a hybrid (part decision tree, part Markov) model. We used a scenario analysis to evaluate alternative time horizons and discount rates. We conducted a threshold analysis to evaluate the impact of variations in the cost of prophylaxis and in the prevalence of sexually transmitted infections (gonorrhea and chlamydia). In our model, prophylaxis for ophthalmia neonatorum did not meet a willingness-to-pay threshold of Can$50 000 per quality-adjusted life-year (QALY). Although prophylaxis was effective in reducing morbidity associated with ophthalmia neonatorum, the number needed to treat to prevent 1 case of ophthalmia neonatorum blindness was 500 000, with an associated cost of more than Can$4 000 000. When compared with no prophylaxis, prophylaxis had an incremental cost of Can$355 798 per long-term QALY gained (incremental cost-effectiveness ratio). We found that prophylaxis for ophthalmia neonatorum, although individually inexpensive, leads to very high costs on a population level. These findings contribute to the discussion on mandatory prophylaxis currently underway in several jurisdictions.

1334. Radiographic Features Associated with Increased Microbiology Culture Yields in Pediatric Orbital Cellulitis

Abstract Background Orbital cellulitis is an invasive infection defined by its location posterior to the orbital septum and can result in severe clinical manifestations. Computed tomography (CT) is the recommended imaging modality to assess for extent of disease and the Chandler classification system is used. It has 5 stages (CS): I is preseptal; II has inflammation beyond the orbital septum; III has subperiosteal abscess; IV has orbital abscess; and V has cavernous sinus thrombosis. There is limited data in its association with microbiology culture results. As part of a larger study to capture epidemiological and microbiological trends in pediatric orbital we hypothesize that culture yields and identification of a causative pathogen would increase as CS increases. Methods We performed a retrospective analysis using the US Military Health System database. ICD9/10 codes identified Individuals ≤ 21 years from June 2009 to September 2019 with orbital cellulitis. We excluded ophthalmia neonatorum and any cases without radiographic confirmation of orbital involvement. Demographic data, co-morbid diagnoses, imaging studies, microbiology results, and antibiotics prescribed were collected. CT reports were reviewed, and cases grouped by Chandler stage, (CS II-V). Descriptive statistics and χ 2 tests were used for categorical variables when appropriate. Results 130 cases met the inclusion criteria. 66.9% were male, the median age was 9 years old (IQR 4-17), and 55.4% had a prior diagnosis of sinusitis. 50.7% of cases were classified as CS II, 35.3% as CS III, 13.1% as CS IV, and 0.01% as CS V. Microbiology cultures were positive in 33.8% of cases. There was a significant difference between CS and any culture positivity with p = 0.011 and there was a significant trend between increasing CS and culture positivity with p < 0.003. Staphylococcus aureus and Streptococcus intermedius were the two most commonly identified pathogens, with no significant difference or trend associated with CS. Conclusion Overall, our findings demonstrated microbiology yield being low but increases with radiographic characteristics and CS stage. Identification of causative pathogens could increase the likelihood for tailored definitive antimicrobial therapy in pediatric patients with orbital cellulitis. Disclosures All Authors: No reported disclosures.

67 Is Ophthalmia Neonatorum associated with Invasive Bacterial Infection? A single centre retrospective study

Abstract Background The immature immune system of neonates puts them at an increased risk of invasive bacterial infections (IBI). Ocular complications due to ophthalmia neonatorum (ON) are well described, unlike the association with IBI for which only case reports of ON with bacteremia and meningitis are documented. The risk of IBI in neonates with ophthalmia neonatorum (ON) is poorly known and part of the issue is the lack of clinical data. Objectives Our objective was to document the association of ON with IBI. Design/Methods This is a retrospective observational chart review of all afebrile neonates who presented to a single emergency department (ED) between January 2018 and December 2019 and were diagnosed with ON. Newborns with craniofacial malformations and premature infants were excluded. The primary outcome was IBI as defined by growth of any bacterial pathogen in the blood or cerebrospinal fluid. Perinatal risk factors, ED visit details (symptoms on presentation, management and treatment plan) as well as complications (ocular morbidity, death and unscheduled return visits to the ED) were collected. Data were analyzed using descriptive statistics. Results Fifty-two neonates were included in this retrospective review. There were no case of IBI associated with ON (0%, 95%CI 0-6.9%). Six ocular bacterial infections were identified, one of which was C trachomatis. Although there was no IBI, ocular complications, death or unscheduled return visits to the ED, there was a wide variation in physician management of ON. Physicians performed at least para-clinical investigation in 49% (95%CI: 34-62%) of neonates, prescribed antibiotics to 87% (95% CI: 74-94%) and involved specialists in 39% (95%CI: 27-52%) of cases. Most neonates were discharged home (92%; 95%CI: 81-98%) and three neonates (6%; 95%CI: 1-16%) were admitted to the hospital following their ED visit. Conclusion ED presentations of afebrile neonates with ON are associated with a low risk of IBI. A better understanding of the current practice variation is needed to inform clinical guidelines for the management of term neonates with ON presenting to the ED.