What is the recommended treatment for bacterial conjunctivitis?

Treatment of Bacterial Conjunctivitis

A 5-7 day course of broad-spectrum topical antibiotic is the recommended treatment for bacterial conjunctivitis as it accelerates clinical and microbiological remission, reduces transmissibility, and allows earlier return to school/work. 1, 2

Treatment Approach Based on Severity

Mild Bacterial Conjunctivitis

• Apply a broad-spectrum topical antibiotic 4 times daily for 5-7 days, with the most convenient or least expensive option being appropriate as there is no clinical evidence suggesting superiority of any particular antibiotic 2
• Topical antibiotics significantly improve clinical cure rates by day 3-5 (62% vs 28% with placebo) and enhance eradication of causative organisms (71% vs 19% with placebo) 3
• While mild bacterial conjunctivitis may resolve spontaneously in immunocompetent adults, antibiotic treatment shortens the duration of symptoms and reduces transmissibility 2, 4

Moderate to Severe Bacterial Conjunctivitis

• Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 1, 2
• More aggressive treatment is required for cases characterized by copious purulent discharge, pain, and marked inflammation 2
• Compounded topical antibiotics, such as vancomycin, may be required for resistant organisms like MRSA 2

Recommended Antibiotics

• Fluoroquinolones (e.g., moxifloxacin, gatifloxacin) are effective against common pathogens causing bacterial conjunctivitis 1

  • Moxifloxacin 0.5% ophthalmic solution: Instill one drop in the affected eye 3 times a day for 7 days 5
  • Moxifloxacin is effective against a broad spectrum of pathogens including Staphylococcus species, Streptococcus pneumoniae, Haemophilus influenzae, and Chlamydia trachomatis 5
  • Gatifloxacin is effective against Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Haemophilus influenzae 6

• Other recommended antibiotics include gentamicin, tetracycline, and ofloxacin 1

• Ciprofloxacin, chloramphenicol, and rifampin have shown activity against the most prevalent pathogens (H. influenzae and S. pneumoniae) 7

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics and can be considered when access to antibiotics is limited 1, 2

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 1, 2
• Daily follow-up until resolution of conjunctivitis is necessary 2
• Saline lavage promotes comfort and faster resolution of inflammation 1

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 1, 2
• For neonates with chlamydial conjunctivitis, oral erythromycin base or ethylsuccinate 50 mg/kg/day divided into four doses daily for 14 days is recommended 1
• Follow-up evaluation is important as treatment failure can occur in up to 19% of cases 2

Common Pitfalls and Caveats

• Bacterial resistance is a growing concern, particularly with MRSA infections 1, 2
• Poor adherence to frequent administration regimens can contribute to treatment failure 1
• Return for follow-up if no improvement after 3-4 days of treatment 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Prolonged antibiotic use may result in overgrowth of non-susceptible organisms, including fungi 5
• Patients should be advised not to wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 5