Treatment of Bacterial Conjunctivitis
For bacterial conjunctivitis, topical antibiotics such as gatifloxacin 0.5% ophthalmic solution should be administered every two hours on day 1, then 2-4 times daily for days 2-7 to effectively treat the infection and allow earlier return to normal activities. 1
Diagnosis and Presentation
Bacterial conjunctivitis typically presents with:
- Mucopurulent discharge
- Eyelids matted shut, especially upon waking
- Lack of itching (distinguishes from allergic conjunctivitis)
- No history of previous conjunctivitis 2
While no single sign or symptom can definitively differentiate bacterial from viral conjunctivitis, bacterial conjunctivitis is more common in children, while viral and allergic forms are more prevalent in adults 2.
First-Line Treatment
Standard Cases (Non-Severe)
- Topical fluoroquinolones are effective first-line agents:
Special Considerations
Neonatal conjunctivitis: Requires systemic antibiotics based on onset:
- 1-7 days after birth: Treat for gonococcal infection (ceftriaxone)
- 5-19 days: Treat for chlamydial infection (erythromycin)
- First week: Common bacterial pathogens (S. aureus, Enterococcus, etc.) 3
Gonococcal/chlamydial infections: Require systemic treatment in addition to topical therapy 3, 4
Treatment Duration and Expectations
- Most uncomplicated cases resolve in 1-2 weeks 4
- Topical antibiotics decrease duration of symptoms and allow earlier return to school or work 4
- Children can typically return to school after 24 hours of antibiotic treatment 3
Antibiotic Selection Considerations
Fourth-generation fluoroquinolones (gatifloxacin, moxifloxacin) have better coverage of gram-positive pathogens than earlier generations 5. Moxifloxacin has high potency and favorable pharmacokinetics, allowing for a three-times-daily dosing schedule 6.
Besifloxacin 0.6% is also effective for bacterial conjunctivitis with potency similar to fourth-generation agents 5.
Prevention of Transmission
- Strict personal hygiene with frequent handwashing
- Avoid sharing towels, washcloths, and pillows
- For children with bacterial conjunctivitis, return to school is appropriate after 24 hours of antibiotic treatment 3, 2
When to Refer to Ophthalmology
Immediate referral is necessary for:
- Neonatal conjunctivitis
- Severe pain or decreased vision
- Recent ocular surgery
- Vesicular rash on eyelids or nose
- History of rheumatologic disease
- Immunocompromised patients
- No improvement after 3 weeks of treatment 3, 2
Potential Pitfalls
Antibiotic resistance: Methicillin-resistant S. aureus (MRSA) has been isolated with increasing frequency. Fourth-generation fluoroquinolones are generally poorly effective against MRSA 5.
Contact lens wear: Patients should be advised not to wear contact lenses during the course of treatment for bacterial conjunctivitis 1.
Superinfection: Prolonged antibiotic use may result in overgrowth of nonsusceptible organisms, including fungi. If superinfection occurs, discontinue use and institute alternative therapy 1.