While every attempt has been made to ensure that the information contained herein is clinically accurate and current, Perinatal Services BC acknowledges that many issues remain controversial, and therefore may be subject to practice interpretation# 
In July 2018 the government of British Columbia repealed section 17 of the Health Act Communicable Disease Regulation that mandated universal newborn baby eye prophylaxis Perinatal Services BC (PSBC) recommends the following:
All women should be offered screening for Chlamydia trachomatis and Neisseria gonorrhoeae at the first prenatal visit 1,2   Additional screening is recommended in each trimester for women with ongoing risk factors 1,2   Universal eye prophylaxis of all newborns to prevent Ophthalmia Neonatorum, caused by Chlamydia trachomatis and Neisseria gonorrhoeae, until there is a safe alternative to erythromycin, such as rapid screening for women who have not been screened during pregnancy or with ongoing risk factors at the time of delivery for Chlamydia trachomatis and Neisseria gonorrhoeae The only agent approved in Canada for newborn eye prophylaxis is erythromycin 3   Monitor all newborns for signs and symptoms of Ophthalmia Neonatorum It is imperative for both health care providers and parents to recognize the signs and symptoms of Ophthalmia Neonatorum and to respond appropriately 2,4,5,6   If infection is suspected collect conjunctival specimen and test for Chlamydia trachomatis and Neisseria gonorrhoeae   Cefotaxime is the recommended treatment for infants at risk for, or diagnosed with, Ophthalmia Neonatorum caused by Neisseria gonorrhoeae Due to adverse reactions associated with ceftriaxone in the neonatal population, cefotaxime is the preferred antimicrobial 7,8   Consider a single dose of intramuscular cefotaxime prior to discharge if the infant is at risk for exposure to Neisseria gonorrhoeae and there is any concern that the mother or caregiver may not recognize the signs of Ophthalmia Neonatorum, and/or respond appropriately 2,6   Asymptomatic infants born to mothers with untreated Neisseria gonorrhoeae infection at the time of birth should receive a single dose of cefotaxime 100 mg/kg IV/IM 2
Infants born to mothers with untreated Neisseria gonorrhoeae at the time of birth that are unwell require: Treat infants that test positive for Chlamydia trachomatis with oral or intravenous erythromycin 4,6,9,10 
 A full

# Highlights of this Guideline
Ophthalmia Neonatorum (ON) is defined as acute conjunctivitis of any cause during the neonatal period and presents with conjunctival erythema, edema of the eyelids and ocular discharge Causes of ON can be chemical, viral or bacterial This guideline focuses on Ophthalmia Neonatorum caused by Chlamydia trachomatis and Neisseria gonorrhoeae and discusses best evidence-based practice to prevent, diagnose, and manage ON caused by these two pathogens This document is intended for use by physicians, midwives, nurse practitioners, acute care and public health nurses who provide health care to newborns in British Columbia It incorporates recommendations and evidence-based information from a variety of trusted sources including provincial, national and international guidelines Experts and stakeholders across BC were consulted during the development of this document A parent information brochure (Appendix A) has been developed to provide parents and/or caregivers with information about the signs and symptoms of Ophthalmia Neonatorum and when to bring the newborn for consultation with a health care provider Primary care providers are responsible for providing this resource to patients, which can be downloaded and printed from Perinatal Services BC's website: www.perinatalservicesbc.ca/health-professionals/guidelines-standards/newborn
The Highlights of this Guideline (on page 2) is a quick reference guide and is intended to serve as a high-level overview of information and action items that are considered relevant in the prevention and management of Ophthalmia Neonatorum caused by Chlamydia trachomatis and Neisseria gonorrhoeae This document is provided for guidance and is not meant to replace clinical judgment

# Executive Summary
Chlamydia trachomatis is the most commonly reported sexually transmitted infection in Canada 11 , and the most common pathogen causing Ophthalmia Neonatorum Approximately 23 per cent 12 of infants born to women with active and untreated Chlamydia trachomatis infections typically present with mild to moderate conjunctivitis Fifty per cent of these infants will also develop a nasopharyngeal infection and 10 to 20 per cent of these infants may develop a concomitant pneumonia 13 Complications from Ophthalmia Neonatorum caused by Neisseria gonorrhoeae are more severe and can lead to corneal scarring, ocular perforation and blindness Skin wounds, such as scalp lesions due to fetal scalp electrodes, may become infected and disseminated infection can also occur 4,14 Two to 40 per cent of infants born to women with active and untreated Neisseria gonorrhoeae infection, and who did not receive eye prophylaxis, may develop Ophthalmia Neonatorum 14,15,16 Neonatal eye prophylaxis was introduced by Crede in 1881 at a time when the maternal infection rates were high and there was no effective treatment for gonococcal Ophthalmia Neonatorum Crede found that routine prophylaxis with topical 2% silver nitrate led to a dramatic reduction in the incidence of blindness caused by gonococcal Ophthalmia Neonatorum 11 The discovery of antibiotics, prenatal screening and treatment of maternal sexually transmitted infections has had a dramatic effect on the prevention of Ophthalmia Neonatorum caused by Chlamydia trachomatis and Neisseria gonorrhoeae 17 As of January 2000, gonococcal Ophthalmia Neonatorum was removed from national surveillance in Canada due to its low incidence Several western countries abandoned prophylaxis in the 1960s in favor of monitoring, swabbing suspicious discharges and treating with appropriate solutions as required 17 Eye prophylaxis is mandatory in the USA 18 ; however, the US Preventative Task Force is currently reviewing the effectiveness of different eye prophylaxis agents to prevent Ophthalmia Neonatorum and blindness, as well as the potential harms related to eye prophylaxis 19 The American Academy of Pediatrics is currently advocating for the revision of mandated eye prophylaxis, and improvement of antenatal screening to prevent Ophthalmia Neonatorum 4
In July 2018 the government of British Columbia repealed section 17 of the Health Act Communicable Disease Regulation that mandated universal newborn eye prophylaxis Currently there are no other legislatively mandated communicable disease prophylaxis or treatment measures, even for immunization programs that do protect and improve public health Mandating babies' eye prophylaxis infringes on the autonomy of the parent as surrogate decision maker and does not necessarily protect or improve public health 17 In Canada, newborn eye prophylaxis remains to be mandated in all provinces/territories except for New Brunswick, Newfoundland, Saskatchewan and now British Columbia Although New Brunswick, Newfoundland and Saskatchewan do not mandate newborn eye prophylaxis it is still recommended and part of their policy Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in BC Since 2003 a steady increase in the prevalence of both Chlamydia trachomatis and Neisseria gonorrhoeae have been noted in the BC population, echoing the national trend This can be attributed to a true rise in disease, improved screening and uptake of testing, and an increase in the sensitivity of diagnostic testing 10,11,20,21 The increase in the reported prevalence of Neisseria gonorrhoeae can also be attributed to updated national guidelines promoting specimen collection from oropharyngeal and rectal sites 5,22 and antibiotic resistance 23,24 Between 2014 to 2016, a 70 per cent increase in the prevalence of Neisseria gonorrhoeae in BC has been noted, leading the BC CDC to collaborate with the National Microbiology Laboratory to determine the reason for this rapid rise 20 The highest prevalence among people of reproductive age is among those aged less than 25 years Rates for the Overview less than 1-year old group for Chlamydia trachomatis in BC between 2003 and 2016 are less than 3/100,000 During this time period, no cases of Neisseria gonorrhoeae in the same population group were reported except in 2014 (23/100,000), following the increase in prevalence observed in the adult population between 2014 and 2016 20

# Case For or Against Universal Eye Prophylaxis and Impact on Care
The Canadian Pediatric Society (CPS) 2015 Position Statement (reaffirmed 2018) on preventing Ophthalmia Neonatorum argues against universal mandated eye prophylaxis and recommends universal screening for Chlamydia trachomatis and Neisseria gonorrhoeae of all pregnant women at the first prenatal visit Women (and sexual partners) who tested positive for Chlamydia trachomatis and/or Neisseria gonorrhoeae need to be treated and retested after treatment to ensure that the treatment was effective The CPS recommends additional targeted testing during the third trimester of all pregnant women who tested positive for Chlamydia trachomatis and Neisseria gonorrhoeae during the first trimester, as well as all women at risk for contracting Chlamydia trachomatis and Neisseria gonorrhoeae Rapid screening for Chlamydia trachomatis and Neisseria gonorrhoeae should be available for all women at delivery who were not screened during their pregnancy 2 This position statement is not supported by the Canadian Association for Pediatric Ophthalmology and Strabismus (CAPOS) citing concerns with the quality of evidence against eye prophylaxis, and the increased risk to infants born to women of marginalized communities with limited access to prenatal care 25 While the CPS Position Statement advocates for comprehensive antenatal screening for Chlamydia trachomatis and Neisseria gonorrhoeae, data collected between 2011 and 2014 in Manitoba indicates that antenatal screening is suboptimal and implies that some infants may be at higher risk to develop gonococcal Ophthalmia Neonatorum without universal eye prophylaxis 26 Finding current evidence-based research relevant to the Canadian population, and specific to the British Columbia population, on Ophthalmia Neonatorum and eye prophylaxis is challenging Much of the primary research was conducted in countries other than Canada, some dating back to the 1980s The Canadian Agency for Drugs and Technologies in Health (CADTH) Rapid Response Report on neonatal eye prophylaxis (2016) concluded that the evidence for, or against, eye prophylaxis is of low quality due to different populations, settings and issues with heterogeneity 27 A Cochrane systemic review on the interventions for preventing Ophthalmia Neonatorum is currently underway The two main objectives of the Cochrane review are to determine if eye prophylaxis reduces the incidence of Ophthalmia Neonatorum, and if so, what eye prophylaxis is the most effective 28 The only agent approved in Canada for eye prophylaxis is erythromycin 3 The efficacy of topical erythromycin to prevent Chlamydia trachomatis Ophthalmia Neonatorum is questionable 29,30,31,32 and not recommended by the American Academy of Pediatrics 14 and the Canadian Pediatric Society 17 Antimicrobial resistance is a global barrier to the successful treatment of Neisseria gonorrhoeae and will have a significant impact on the health and economic burden to manage this disease The Canadian Antimicrobial Resistance Surveillance System (2017) reported a 325 per cent failure rate when treating Neisseria gonorrhoeae with erythromycin 33 , and according to the Canadian Pediatric Society, is the reason for discontinuation of using erythromycin as ocular prophylaxis 12 The incidence of suboptimal antenatal screening rates, the prevalence of Chlamydia trachomatis and/or Neisseria gonorrhoeae infections in pregnant women, and the potential for adverse obstetric outcomes and newborn morbidities due to Chlamydia trachomatis and/or Neisseria gonorrhoeae lend support to the recommendation to improve antenatal screening and the continuation of universal newborn eye prophylaxis Overview, cont'd.

# Screening
All women should be screened for Chlamydia trachomatis and Neisseria gonorrhoeae at the first prenatal visit. Targeted screening is recommended in each trimester for women with ongoing risk factors.
Currently, Perinatal Services BC (PSBC) recommends that all women should be offered screening for Chlamydia trachomatis and Neisseria gonorrhoeae at the first prenatal visit In addition to screening all women at the first prenatal visit, additional screening is recommended in each trimester for women with ongoing risk factors 1 Maternal Risk factors are as follows:
25 years or younger and sexually active 9,23,24,34,35,36,37,38   New and/or more than one sex partner 9,24,36,37,38   Previous documented diagnosis of Chlamydia trachomatis and/or Neisseria gonorrhoeae 5,9,35,36,37,38,39   Sexual contact with a person with suspected or confirmed Chlamydia trachomatis and/or Neisseria gonorrhoeae infection 5,35,36   Unprotected sex with a resident from area with high prevalence of Chlamydia trachomatis and/or Neisseria gonorrhoeae infection 5,36
Unprotected sexual contact with resident from area with high risk of antimicrobial resistance to Chlamydia trachomatis and/or Neisseria gonorrhoeae 5,36 Maternal health care providers must inform newborn's health care providers regarding maternal risk factors, screening results and treatment for Chlamydia trachomatis and Neisseria gonorrhoeae as this will direct the care of the newborn related to Ophthalmia Neonatorum 2
For the most current information on disease prevalence in an area consult the BC Centre for Disease Control Reportable Disease Dashboard: www.bccdc.ca/health-info/disease-system-statistics/reportable-disease-dashboard

# Recommendations Eye Prophylaxis
Universal eye prophylaxis of all newborns to prevent Ophthalmia Neonatorum caused by Chlamydia trachomatis and Neisseria gonorrhoeae is recommended.
While the law mandating universal eye prophylaxis has been repealed, PSBC and CAPOS continue to recommend universal eye prophylaxis of the newborn until there is a safe alternative to erythromycin such as rapid maternal screening at the time of delivery for Chlamydia trachomatis and Neisseria gonorrhoeae Currently erythromycin 05% ointment is the only ocular prophylactic agent approved in Canada and needs to be administered within one hour after birth 3
Procedure to Administer 0.5% Erythromycin Ointment 1 Use gloves when administering erythromycin 2 To prevent cross contamination, use a single-use tube of 05% erythromycin and discard remainder of tube after administering to both eyes 3 Before administration, wipe each eyelid gently with sterile cotton to remove foreign matter and to permit adequate eversion of the lower lid 4 Apply a line of 05% erythromycin ointment, about 1 cm long, in the inferior conjunctival fornix, by pulling the lower eyelid gently down Care is needed to prevent injury to the eye or the eyelid from the tip of the tube 5 Gently massage the closed eyelids to help spread the solution to all areas of the conjunctiva 6 In the very premature newborns whose eye lids are fused at the time of birth, apply the erythromycin ointment without separating the eyelids Ointment absorption through the immature skin is expected
Recommendations, cont'd.

# Monitor for Signs and Symptoms of Ophthalmia Neonatorum
It is imperative for both health care providers and parents to recognize the signs and symptoms of Ophthalmia Neonatorum and to respond appropriately 2,4,5,6 Advise mother or caregiver of all newborns how to recognize Ophthalmia Neonatorum prior to discharge and when to contact a health care provider (see Appendix A: Information for Families) Currently, erythromycin 05% ointment is the only prophylactic agent approved in Canada and needs to be administered within one hour after birth 3 It is recommended that erythromycin eye prophylaxis continues to be administered to all newborns until there is a safe alternative, including newborns at risk of exposure to Neisseria gonorrhoeae Advise mother or caregiver how to recognize Ophthalmia Neonatorum prior to discharge and when to contact a health care provider (see Appendix A: Information for Families) If there is any concern that the mother or caregiver may not recognize the signs of Ophthalmia Neonatorum and/or respond appropriately, consider administering a single dose of cefotaxime IM prior to discharge if the newborn is discharged before five days of age 3 Prophylactic antibiotic treatment is not indicated unless follow up with physician cannot be guaranteed 14,17 4 Newborns should be monitored for signs of Chlamydia trachomatis infection (conjunctivitis and/or pneumonitis) 2,4,5,6 5 Advise mother how to recognize Ophthalmia Neonatorum prior to discharge and when to contact a health care provider (see Appendix A: Information for Families)
Management of Ophthalmia Neonatorum Caused by Chlamydia trachomatis 1 Collect conjunctival swabs obtained from the everted eyelid Specimens must contain conjunctival cells, not just exudate 30 Test for Neisseria gonorrhoeae at the same time 2 Treat infant if test is positive for Chlamydia trachomatis with oral or intravenous erythromycin 4,6,9,10 Dosing and frequency of administration are determined by weight and postnatal age 41 Consult local guidelines for neonatal dosing information 3 Consider referral to higher level of care if indicated 4 There is a documented association between orally administered erythromycin and infantile hypertrophic pyloric stenosis- especially in newborns less than two weeks of age 4,10,42 5 Inform parents about the signs and potential risks of developing infantile hypertrophic pyloric stenosis- (nonbilious and forceful vomiting immediately after feed) 6 Follow up visit with newborn three to four weeks after completion of the treatment is recommended since the efficacy of erythromycin therapy is approximately 80% A second course of treatment may be required 4 - Functional gastric outlet obstruction leading to forceful vomiting
Management of the Newborn at Risk of Exposure to Chlamydia trachomatis
Appendix A: Information for Families: Eye Infection and Your Newborn Baby www.perinatalservicesbc.ca Most of the time, puffy or red eyes in your baby are caused by a blocked tear duct or infection by viruses or bacteria. Some eye infections may be serious and need special medication.
Contact your doctor or go to the emergency department or health clinic at once if your baby is under two weeks and:
- Your baby's eyes are red - Your baby's eyes have thick pus
- Your baby's eyelids are swollen or puffy Your baby's eye needs to be examined to find out if it is an infection that needs to be treated.