What is the first line medication for bacterial conjunctivitis?

First-Line Medication for Bacterial Conjunctivitis

Topical fluoroquinolones, particularly ofloxacin, gentamicin, or tetracycline, are recommended as first-line treatments for bacterial conjunctivitis. 1

Rationale for Treatment Selection

Bacterial conjunctivitis typically presents with:

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

The most common causative organisms include:

• Staphylococcus aureus
• Staphylococcus epidermidis
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella species

Treatment Algorithm

First-Line Options:

1. Topical fluoroquinolones:

   • Ofloxacin ophthalmic solution 1
   • Moxifloxacin 0.5% ophthalmic solution (effective against common pathogens including S. aureus, S. epidermidis, S. pneumoniae, and H. influenzae) 2
   • Gatifloxacin ophthalmic solution (effective against S. aureus, S. epidermidis, S. pneumoniae, and H. influenzae) 3

2. Other first-line options:

   • Topical gentamicin
   • Topical tetracycline 1

Standard Treatment Course:

• Apply drops 3 times daily for 5-7 days 1, 2
• Continue until:
  • Resolution of discharge
  • No more matting of eyelids in the morning
  • Reduction in conjunctival injection 1

Special Considerations

For Specific Pathogens:

• Gonococcal conjunctivitis: Requires BOTH systemic and topical therapy

  • Systemic: Ceftriaxone (single dose)
  • Plus topical antibiotic therapy 1

• Chlamydial conjunctivitis: Requires systemic therapy

  • Azithromycin (1g orally, single dose) OR
  • Doxycycline (100mg orally twice daily for 7 days) OR
  • Levofloxacin (500mg orally once daily for 7 days) 1

Antibiotic Resistance Concerns:

• Increasing resistance to fluoroquinolones has been reported, particularly in methicillin-resistant Staphylococcus aureus (MRSA) isolates 1
• Recent studies show that fluoroquinolones remain effective against staphylococci associated with conjunctivitis 4

Evidence Quality and Effectiveness

Topical antibiotics have been shown to:

• Increase clinical remission rates on days 2-5 (RR 1.36; 95% CI, 1.15-1.61)
• Improve microbiological remission (RR 1.55; 95% CI, 1.37-1.76)
• Provide modest benefits through days 6-10 5

Without treatment, approximately 41% of bacterial conjunctivitis cases resolve spontaneously by days 6-10 5, but treatment allows for earlier symptom resolution and return to work or school.

Important Caveats

• Delayed antibiotic prescribing may be considered for mild cases 1
• Avoid indiscriminate use of antibiotics, as viral conjunctivitis will not respond to antibacterial agents 1
• Avoid topical corticosteroids as they can potentiate infections 1
• Patients should not wear contact lenses during treatment 2
• Refer to ophthalmology 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 status 1

By following this treatment approach, most cases of bacterial conjunctivitis will resolve quickly with minimal complications, improving patient quality of life and reducing morbidity.