What is the treatment for bacterial conjunctivitis?

Treatment of Bacterial Conjunctivitis

The first-line treatment for bacterial conjunctivitis is topical antibiotic therapy, with broad-spectrum options including ciprofloxacin, polymyxin B-bacitracin, trimethoprim-polymyxin B, gentamicin, tetracycline, or ofloxacin for a standard course of 5-7 days. 1

Clinical Presentation and Diagnosis

Bacterial conjunctivitis typically presents with:

• Purulent or mucopurulent discharge
• Matting of eyelids (especially upon waking)
• Conjunctival injection (redness)
• Mild discomfort or foreign body sensation
• Absence of significant pain or vision loss 1

Common causative organisms include:

• Haemophilus influenzae
• Streptococcus pneumoniae
• Staphylococcus aureus
• Staphylococcus epidermidis
• Moraxella species 1, 2

Treatment Algorithm

Standard Cases

1. First-line treatment options:

   • Topical gentamicin
   • Topical tetracycline
   • Topical ofloxacin
   • Ciprofloxacin
   • Polymyxin B-bacitracin
   • Trimethoprim-polymyxin B 1

2. Newer fluoroquinolone option:

   • Gatifloxacin 0.5% ophthalmic solution: One drop every two hours while awake (up to 8 times) on Day 1, then one drop 2-4 times daily on Days 2-7 3
   • Moxifloxacin 0.5% ophthalmic solution: Effective against common pathogens including S. aureus, S. epidermidis, S. pneumoniae, and H. influenzae 1

3. Duration of treatment:

   • Standard course: 5-7 days
   • Continue until:
     • Resolution of discharge
     • No more matting of eyelids in the morning
     • Reduction in conjunctival injection 1

Special Cases

1. Gonococcal conjunctivitis:

   • BOTH systemic and topical therapy required
   • Systemic: Ceftriaxone (single dose)
   • Plus topical antibiotic therapy 1

2. Chlamydial conjunctivitis:

   • Systemic therapy with one of:
     • Azithromycin (1g orally, single dose) OR
     • Doxycycline (100mg orally twice daily for 7 days) OR
     • Levofloxacin (500mg orally once daily for 7 days) 1

3. Neonatal conjunctivitis:

   • Requires prompt evaluation and treatment based on timing:
     • 1-7 days after birth: Consider gonococcal infection
     • 5-19 days: Consider chlamydial infection
     • First week: Common bacterial infection (S. aureus, Enterococcus, Klebsiella, E. coli) 1

Considerations for Antibiotic Selection

• Fluoroquinolones like gatifloxacin and moxifloxacin offer broad-spectrum coverage and excellent tissue penetration 4
• Gatifloxacin 0.5% is FDA-approved for bacterial conjunctivitis caused by:
  • S. aureus, S. epidermidis, S. pneumoniae (gram-positive)
  • H. influenzae (gram-negative) 3
• Increasing resistance to fluoroquinolones has been reported, particularly in MRSA isolates 1
• Delayed antibiotic prescribing may be considered for mild cases 1, 5

Prevention and Infection Control

• Frequent handwashing
• Avoid sharing towels and pillowcases
• Proper disinfection of surfaces
• Patients with bacterial conjunctivitis can typically return to work or school after 24 hours of antibiotic treatment 1

When to Refer to Ophthalmology

Refer if:

• No 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 1, 5

Important Caveats

• Indiscriminate use of antibiotics should be avoided as mild bacterial conjunctivitis is often self-limiting 1, 6
• Contact lens wearers should discontinue lens wear during treatment 3
• Patients should be advised not to wear contact lenses if they have signs and symptoms of bacterial conjunctivitis 3
• Prolonged use of antibiotics may result in overgrowth of nonsusceptible organisms, including fungi 3