What is the management of conjunctivitis in infants?

Management of Conjunctivitis in Infants

Topical broad-spectrum antibiotics for 5-7 days are the recommended first-line treatment for bacterial conjunctivitis in infants, with systemic antibiotics required for specific pathogens like Chlamydia and Neisseria gonorrhoeae. 1

Diagnosis and Classification

Proper management begins with accurate diagnosis based on:

• Time of onset: Helps identify likely pathogens

  • 1-7 days after birth: Suspect gonococcal infection
  • 5-19 days: Suspect chlamydial infection
  • First week: Common bacterial pathogens (S. aureus, Enterococcus, Klebsiella, E. coli) 1

• Discharge characteristics:

  • Purulent/mucopurulent: Bacterial (most common in infants)
  • Watery: Viral
  • Mucoid with itching: Allergic 1, 2

Treatment Algorithm

1. Bacterial Conjunctivitis (Most Common in Infants)

• First-line treatment: Topical broad-spectrum antibiotics for 5-7 days 1

  • Options include:
    • Erythromycin ophthalmic ointment: Apply 1 cm ribbon up to six times daily 3
    • Polymyxin B-trimethoprim ophthalmic solution
    • Gentamicin ophthalmic solution
    • Moxifloxacin 0.5% ophthalmic solution 1

• Application technique: Apply directly to the infected eye(s), do not flush after instillation 3

• Duration: Continue for full course even if symptoms improve quickly 1

2. Specific Pathogen Management

For Chlamydial Conjunctivitis:

• Requires systemic therapy (topical alone is insufficient)
• Erythromycin demonstrates 96% clinical and 97% microbiological cure rates 1

For Gonococcal Conjunctivitis:

• Requires both systemic and topical therapy
• For infants born to mothers with clinically apparent gonorrhea:
  • Intravenous/intramuscular aqueous crystalline penicillin G (50,000 units for term infants; 20,000 units for low birth weight infants)
  • Topical prophylaxis alone is inadequate 3

3. Supportive Care

• Warm compresses (preferred over cold for bacterial conjunctivitis) to:

  • Soften discharge
  • Loosen crusts
  • Express meibomian gland secretions that may harbor bacteria 1

• Artificial tears for comfort 1

Prevention and Hygiene Measures

• Prophylaxis at birth: All infants should receive ocular prophylaxis to prevent gonococcal ophthalmia 4

  • Erythromycin ophthalmic ointment: Apply 1 cm ribbon in each lower conjunctival sac
  • Use a new tube for each infant 3

• Infection control:

  • Frequent handwashing by caregivers
  • Separate towels and washcloths
  • Avoid sharing pillowcases
  • Proper disinfection of toys and surfaces 1

When to Refer to Ophthalmology

Immediate referral for:

• Moderate to severe pain
• Visual loss
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Suspected herpes simplex virus (vesicular rash or dendritic lesions)
• Immunocompromised infants 1, 5

Important Clinical Considerations

• Watchful waiting may be appropriate for mild cases, as approximately 50% of cases resolve within four days without antibiotics 6

• However, studies show that antibiotic treatment shortens the course of disease by about half a day, reduces discomfort, prevents person-to-person transmission, and reduces reinfection rates 2, 7

• For cases involving sexually transmitted bacteria (chlamydia, gonorrhea), mothers and their sexual partners should also be treated 4

• Common pitfall: Failing to obtain cultures in neonates with conjunctivitis. Always send conjunctival swabs for Gram stain and culture in neonates to identify specific pathogens 4