How do you differentiate and treat viral versus bacterial conjunctivitis?

From the Guidelines

Differentiating and treating viral versus bacterial conjunctivitis requires careful assessment of symptoms and appropriate management strategies, with viral conjunctivitis typically being self-limiting and requiring supportive care, while bacterial conjunctivitis necessitates topical antibiotic treatment. The key to differentiating between viral and bacterial conjunctivitis lies in their clinical presentations. Viral conjunctivitis, as seen in cases caused by Herpes simplex virus (HSV) or Varicella (herpes) zoster virus (VZV) 1, typically presents with watery discharge, lymphoid follicles on the palpebral conjunctiva, and often begins unilaterally before spreading to the other eye, frequently accompanied by upper respiratory symptoms. It is self-limiting and requires supportive care with artificial tears (e.g., Refresh Tears 1-2 drops 4-6 times daily) and cold compresses for 7-14 days until resolution. No antibiotics are needed for viral cases.

Bacterial conjunctivitis, conversely, presents with purulent discharge, conjunctival injection, and crusting of the eyelids, especially upon waking. Treatment involves topical antibiotics such as erythromycin 0.5% ointment applied 3-4 times daily, fluoroquinolones like moxifloxacin (Vigamox) 1 drop 3 times daily, or polymyxin B-trimethoprim drops 1 drop every 3 hours while awake. These should be continued for 5-7 days, even if symptoms improve earlier. The importance of directing treatment at the root cause of conjunctivitis is emphasized in recent guidelines 1, highlighting the need to avoid indiscriminate use of topical antibiotics or corticosteroids, which can induce toxicity or worsen certain infections.

For both types of conjunctivitis, preventive measures are crucial, including avoiding touching the eyes, washing hands frequently, using separate towels, and discarding eye makeup to prevent spread or reinfection 1. If symptoms worsen, vision becomes affected, or there's no improvement after 48-72 hours of treatment, patients should seek immediate medical attention as this may indicate a more serious condition requiring specialized care. Vaccination strategies, such as the herpes zoster vaccine for adults 50 years or older, can also play a significant role in preventing certain types of viral conjunctivitis 1.

Key considerations in management include:

• Supportive care for viral conjunctivitis
• Topical antibiotics for bacterial conjunctivitis
• Prevention of spread through hygiene practices
• Vaccination against certain viral causes when applicable
• Monitoring for complications or worsening symptoms that may require specialized care.

From the FDA Drug Label

The symptoms of bacterial conjunctivitis may include: discharge coming from the eye, eye redness, eye irritation Bacterial conjunctivitis is a bacterial infection of the mucous membranes which line the inside of the eyelids. Moxifloxacin ophthalmic solution, 0.5% is indicated for the treatment of bacterial conjunctivitis caused by susceptible strains of the following organisms:

The FDA drug label does not answer the question of how to differentiate viral versus bacterial conjunctivitis. Key points to consider when trying to differentiate:

• Symptoms: Bacterial conjunctivitis often presents with discharge, eye redness, and irritation.
• Treatment: Bacterial conjunctivitis is typically treated with antibiotics, such as azithromycin or moxifloxacin.
• Diagnosis: A diagnosis of bacterial conjunctivitis can only be made by a doctor, and may require further testing to confirm. It is essential to consult a doctor for an accurate diagnosis and appropriate treatment, as the FDA drug label does not provide direct guidance on differentiating between viral and bacterial conjunctivitis 2, 3, 3.

From the Research

Differentiation of Viral and Bacterial Conjunctivitis

• The differentiation between viral and bacterial conjunctivitis can be challenging, as there is no single sign or symptom that accurately differentiates between the two 4.
• A comprehensive history and physical examination can guide diagnosis, with viral and allergic conjunctivitis more common in adults and typically presenting with watery discharge 4.
• Bacterial conjunctivitis is more common in children and typically presents as mucopurulent discharge with the eyelids matted shut 4, 5.

Treatment of Viral and Bacterial Conjunctivitis

• Supportive care options for viral conjunctivitis include artificial tears, cold compresses, and antihistamine eye drops 4.
• Topical antihistamines with mast cell-stabilizing activity are the treatment of choice for allergic conjunctivitis 4, 5.
• Bacterial conjunctivitis can be treated with topical antibiotics, which decrease the duration of the infection and allow for an earlier return to school or work 5.
• Delayed antibiotic prescribing has been found to have similar symptom control as immediate prescribing 4.
• In some cases, such as conjunctivitis caused by gonorrhea or chlamydia, or conjunctivitis in contact lens wearers, antibiotic treatment is necessary 5.

Specific Treatment Options

• A fixed-dose combination of moxifloxacin 0.5% and dexamethasone 0.1% has been shown to be therapeutically equivalent and well-tolerated compared to concomitant dosage 6.
• Tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05% has been found to be effective and safe in the treatment of moderate to severe acute blepharitis/blepharoconjunctivitis, providing faster inflammation relief compared to azithromycin 7.

Referral to Ophthalmology

• Ophthalmology referral is indicated for conjunctivitis in a neonate or patients with severe pain, decreased vision, recent ocular surgery, vesicular rash on the eyelids or nose, history of rheumatologic disease, or immunocompromised state 4.
• Patients with prolonged symptoms, poor response to initial management, or evidence of severe disease should also be referred to ophthalmology for consultation 8.