Treatment of Conjunctivitis in Patients with Multiple Antibiotic Allergies
For patients with allergies to fluoroquinolones, macrolides, trimethoprim, and penicillins, topical aminoglycosides such as gentamicin are the recommended first-line treatment for bacterial conjunctivitis. 1, 2
Treatment Algorithm Based on Type of Conjunctivitis
Bacterial Conjunctivitis
- Topical gentamicin is FDA-approved for bacterial conjunctivitis and effective against common pathogens including Staphylococcus, Streptococcus, Haemophilus, and Pseudomonas 2
- Apply gentamicin ophthalmic solution 1-2 drops every 4 hours for 5-7 days for mild to moderate cases 1, 3
- For severe cases, increase frequency to every 2 hours initially, then taper as clinical improvement occurs 1
- Obtain conjunctival cultures before initiating treatment in moderate to severe cases 1
Special Considerations for Specific Bacterial Infections
- For gonococcal conjunctivitis, topical treatment alone is insufficient; systemic therapy with ceftriaxone (if not allergic to cephalosporins) is required along with saline lavage 1
- For chlamydial conjunctivitis, systemic therapy is necessary (doxycycline if not contraindicated) 1
- For MRSA conjunctivitis, vancomycin may be considered as topical therapy 4
Allergic Conjunctivitis
- First-line treatment includes non-pharmacological interventions: 4
- Cold compresses
- Refrigerated artificial tears (preservative-free)
- Allergen avoidance
- Wearing sunglasses as barrier to airborne allergens
- Pharmacological options (all topical): 4
- Antihistamine/vasoconstrictor combinations (over-the-counter)
- Second-generation topical histamine H1-receptor antagonists
- Mast cell stabilizers for recurrent or persistent cases
- Dual-action agents (antihistamine + mast cell stabilizer)
- For inadequate symptom control, consider a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile 4
- In severe cases, topical cyclosporine or tacrolimus can be considered 4
Monitoring and Follow-up
- Follow up within 3-4 days if no improvement with initial therapy 1
- If using topical corticosteroids, monitor for increased intraocular pressure and cataract formation 4
- For allergic conjunctivitis, timing follow-up visits during symptomatic periods is recommended 4
Pitfalls and Caveats
- Avoid indiscriminate use of topical antibiotics as they can induce toxicity 4
- Corticosteroids can potentially prolong adenoviral infections and worsen HSV infections 4
- Chronic use of vasoconstrictors can lead to rebound vasodilation 4
- Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 4
- Bacterial resistance is a growing concern, particularly with MRSA infections 1