Treatment of Bacterial Conjunctivitis
For bacterial conjunctivitis, a 5-7 day course of broad-spectrum topical antibiotic is recommended as it accelerates clinical and microbiological remission, reduces transmissibility, and allows earlier return to school/work. 1
Treatment Approach Based on Severity
Mild Bacterial Conjunctivitis
- Apply broad-spectrum topical antibiotic 4 times daily for 5-7 days 2
- While mild bacterial conjunctivitis may resolve spontaneously in immunocompetent adults, antibiotics shorten the duration of symptoms and improve clinical outcomes 1
- Patients should be advised to return for follow-up if no improvement is seen after 3-4 days of treatment 3
Moderate to Severe Bacterial Conjunctivitis
- Characterized by copious purulent discharge, pain, and marked inflammation 2
- Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 1
- Choice of antibiotic should be guided by laboratory test results 3
- Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly common and may require compounded topical antibiotics such as vancomycin 3
Specific Antibiotic Options
Fluoroquinolones
- Ciprofloxacin: For bacterial conjunctivitis, instill 1-2 drops every 2 hours while awake for 2 days, then 1-2 drops every 4 hours while awake for the next 5 days 4
- Fluoroquinolones are effective against common pathogens including resistant strains 1, 5
Macrolides
- Azithromycin 1.5% ophthalmic solution: Instill 1 drop in affected eye(s) twice daily for first 2 days, then once daily for next 5 days 6, 7
- Particularly effective for H. influenzae and C. trachomatis infections 7
Other Antibiotics
- Chloramphenicol and rifampin show good activity against common conjunctivitis pathogens 8
- Erythromycin is effective for chlamydial conjunctivitis in neonates 1
Special Considerations
Gonococcal Conjunctivitis
- Requires systemic antibiotic therapy rather than topical treatment alone 1
- Saline lavage promotes comfort and faster resolution of inflammation 3
- Daily follow-up until resolution is necessary 3
- Sexual contacts should be informed and treated 3
Chlamydial Conjunctivitis
- Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 1
- Treatment failure can occur in up to 19% of cases, necessitating follow-up evaluation 3
- Sexual contacts should be treated simultaneously 3
Alternative Options
- Povidone-iodine 1.25% ophthalmic solution may be considered when access to antibiotics is limited 1, 2
Common Pitfalls and Caveats
- Bacterial resistance is a growing concern, particularly with MRSA infections 1
- Poor adherence to frequent administration regimens can contribute to treatment failure 1
- Skipping doses or not completing the full course of therapy may decrease effectiveness and increase likelihood of bacterial resistance 6
- For children with gonococcal or chlamydial infections, consider the possibility of sexual abuse 3, 1
- Most common pathogens in bacterial conjunctivitis are Haemophilus influenzae and Streptococcus pneumoniae, followed by Staphylococcus aureus 8, 9