What is the treatment for conjunctivitis?

Treatment of Conjunctivitis

For bacterial conjunctivitis, topical antibiotics such as ofloxacin are recommended with a regimen of one to two drops every 2-4 hours for days 1-2, then four times daily for days 3-7. 1

Diagnosis and Treatment Approach by Type

Bacterial Conjunctivitis

• Clinical presentation: Mucopurulent discharge, mattering and adherence of eyelids upon waking, lack of itching 2, 3
• Common pathogens: Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus epidermidis, and Moraxella species 1, 4
• Treatment:
  1. Topical antibiotics (first-line options):
     • Ofloxacin: 1-2 drops every 2-4 hours for days 1-2, then 1-2 drops four times daily for days 3-7 1
     • Other options: Gentamicin, tetracycline, moxifloxacin 0.5% 5
  2. Duration: Standard treatment course is 5-7 days, continuing until resolution of discharge, no more mattering of eyelids in the morning, and reduction in conjunctival injection 5
  3. Most cases improve within 1-3 days of appropriate antibiotic therapy 5

Viral Conjunctivitis

• Clinical presentation: Watery discharge, often unilateral that becomes bilateral, possible lymphadenopathy 3
• Treatment:
  • Supportive care with artificial tears and cold compresses 3
  • No antibiotics needed as they are ineffective against viral causes 2
  • Patient isolation for 10-14 days from symptom onset to prevent spread 5

Allergic Conjunctivitis

• Clinical presentation: Bilateral itching (most consistent sign), watery discharge, seasonal patterns 2, 3
• Treatment:
  • Topical antihistamines with mast cell-stabilizing activity 3
  • Avoidance of allergens when possible 2

Special Considerations

Neonatal Conjunctivitis

• Requires urgent evaluation and treatment due to risk of serious complications
• For suspected gonococcal conjunctivitis:
  • BOTH systemic (ceftriaxone) AND topical antibiotic therapy 5
  • Collect specimens before starting treatment 5
• For suspected chlamydial conjunctivitis:
  • Systemic therapy with azithromycin, doxycycline, or levofloxacin 5
  • Topical therapy alone is inadequate 5
• Evaluate and treat the mother and her sexual partner(s) 5

When to Refer to Ophthalmology

• Lack of response to therapy after 3-4 days
• Moderate to severe pain
• Decreased vision
• Corneal involvement
• Conjunctival scarring
• Recurrent episodes
• History of herpes simplex virus eye disease
• Immunocompromised patients
• Suspected herpetic conjunctivitis (vesicular lesions, corneal involvement) 5, 3

Evidence on Treatment Efficacy

Research demonstrates that topical antibiotics significantly accelerate recovery from bacterial conjunctivitis. A meta-analysis showed that antibiotics improved early (days 2-5) clinical remission rates (RR 1.36,95% CI 1.15 to 1.61) and microbiological remission rates (RR 1.55,95% CI 1.37 to 1.76) 6. Even at later time points (days 6-10), antibiotics still conferred modest benefits in clinical remission (RR 1.21,95% CI 1.10 to 1.33) 6.

A randomized controlled trial in children showed that by 3-5 days, 62% of patients receiving topical antibiotics were clinically cured compared to only 28% in the placebo group (P < 0.02) 7.

Prevention of Spread

• Frequent handwashing
• Avoid sharing towels and pillowcases
• Proper contact lens care 5
• Patients with bacterial conjunctivitis can typically return to work or school after 24 hours of antibiotic treatment 5

Important Caveats

1. Antibiotic resistance concerns: Increasing resistance to fluoroquinolones has been reported, particularly in MRSA isolates. Consider local resistance patterns when selecting antibiotics 5, 4.

2. Self-limiting nature: While bacterial conjunctivitis is often self-limiting (41% of placebo cases resolve by days 6-10) 6, antibiotics speed recovery and reduce transmission risk.

3. Delayed prescribing: For mild cases, delayed antibiotic prescribing may be considered, as it has similar symptom control as immediate prescribing 5, 3.

4. Conjunctivitis secondary to STDs: Cases due to gonorrhea or chlamydia require systemic treatment in addition to topical therapy 2.

5. Contact lens wearers: These patients should always receive antibiotic treatment due to higher risk of complications 3.