What is the recommended treatment for bacterial conjunctivitis?

Treatment of Bacterial Conjunctivitis

Topical antibiotics are recommended for bacterial conjunctivitis as they reduce symptom duration and improve clinical outcomes, even in mild cases. 1

Treatment Approach Based on Severity

Mild Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is typically self-limiting in immunocompetent adults, with 41% of untreated cases resolving within 6-10 days 2
• A 5-7 day course of broad-spectrum topical antibiotic is recommended as it:
  • Accelerates clinical and microbiological remission in days 2-5 of treatment 1, 2
  • Reduces transmissibility and allows earlier return to school/work 1, 3
  • The most convenient or least expensive option can be selected as there is no evidence suggesting superiority of any particular antibiotic 1

Moderate to Severe Bacterial Conjunctivitis

• Characterized by copious purulent discharge, pain, and marked inflammation 1
• Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 1
• Guide antibiotic selection based on laboratory results 1
• Consider the increasing prevalence of methicillin-resistant S. aureus (MRSA), which may require specialized antibiotics like vancomycin 1

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 1
• Add saline lavage to promote comfort and faster resolution of inflammation 1
• If corneal involvement is present, add topical treatment as for bacterial keratitis 1
• Monitor daily until resolution with visual acuity measurement and slit-lamp examination 1
• Screen and treat sexual contacts 1

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 1
• Empiric antibiotic therapy can be considered for persistent follicular conjunctivitis 1
• No evidence supports additional topical therapy beyond systemic treatment 1
• Re-evaluate after treatment due to potential treatment failure rate of up to 19% 1
• Treat sexual contacts simultaneously 1

Recommended Antibiotics

First-line Options

• The WHO Expert Committee endorses topical gentamicin, tetracycline, and ofloxacin for bacterial conjunctivitis 1
• Fluoroquinolones (e.g., moxifloxacin, gatifloxacin) are effective against common pathogens:
  • Moxifloxacin is indicated for conjunctivitis caused by Staphylococcus species, Streptococcus pneumoniae, Haemophilus influenzae, and Chlamydia trachomatis 4
  • Gatifloxacin is effective against similar pathogens 5

Alternative Options

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics and can be considered when access to antibiotics is limited 1
• Polymyxin-bacitracin has been shown to shorten clinical disease duration and enhance pathogen eradication 6
• Ciprofloxacin, chloramphenicol, and rifampin demonstrate good activity against common pathogens 7

Common Pathogens

• Most common causative organisms include:
  • Haemophilus influenzae (most prevalent in pediatric cases) 7, 8
  • Streptococcus pneumoniae 7, 8
  • Staphylococcus aureus 7, 8
  • Staphylococcus epidermidis 8
  • Moraxella species 8

Pitfalls and Caveats

• Bacterial resistance is a growing concern, particularly with MRSA infections 1, 8
• Poor adherence to frequent administration regimens can contribute to treatment failure 8
• Avoid contact lens wear during active infection 4
• Return for follow-up if no improvement after 3-4 days of treatment 1
• For gonococcal conjunctivitis, rule out Neisseria meningitidis before confirming N. gonorrhoeae as the causative organism 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1