What are the treatment options for bacterial conjunctivitis?

Treatment of Bacterial Conjunctivitis

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

Treatment Based on Severity

Mild to Moderate 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
• Fluoroquinolones (e.g., moxifloxacin, gatifloxacin) are effective against common pathogens and are frequently prescribed 1, 2
• Moxifloxacin 0.5% ophthalmic solution is indicated for bacterial conjunctivitis caused by susceptible strains of common ocular pathogens including Staphylococcus species, Streptococcus pneumoniae, and Haemophilus influenzae 2
• Recommended dosage for moxifloxacin is one drop in the affected eye 3 times a day for 7 days 2
• Ciprofloxacin dosage for bacterial conjunctivitis is one or two drops instilled into the conjunctival sac every two hours while awake for two days, then every four hours while awake for the next five days 3
• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics and can be considered when access to antibiotics is limited 4, 1

Moderate to Severe Bacterial Conjunctivitis

• Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 4, 1
• Choice of antibiotic should be guided by laboratory test results in severe cases 4
• Consider methicillin-resistant S. aureus (MRSA) in cases not responding to standard therapy, as it has been isolated with increasing frequency 4

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 4, 1
• Saline lavage may promote comfort and more rapid resolution of inflammation 4
• Daily follow-up is recommended until resolution 5
• Patients and sexual contacts should be informed about the possibility of concomitant disease and referred appropriately 4

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 4, 1
• No evidence supports additional topical therapy beyond systemic treatment 1
• Sexual contacts should be treated simultaneously 4

Common Pathogens and Antibiotic Selection

• Most prevalent bacteria in bacterial conjunctivitis are Haemophilus influenzae (44.8%) and Streptococcus pneumoniae (30.6%), followed by Staphylococcus aureus (7.5%) 6
• Ciprofloxacin, chloramphenicol, and rifampin have shown good activity against the most prevalent pathogens 6
• Moxifloxacin has demonstrated good activity against various Gram-positive and -negative ocular isolates in vitro 7

Follow-up Care

• Patients should be advised to return for evaluation in 3-4 days if no improvement is noted 4, 5
• If no improvement is seen after 3-4 days of treatment, the diagnosis should be reevaluated or resistant organisms considered 5

Pitfalls and Caveats

• Bacterial resistance is a growing concern, particularly with MRSA infections 4, 8
• Poor adherence to frequent administration regimens can contribute to treatment failure 8
• Prolonged use of antibiotics may result in overgrowth of non-susceptible organisms, including fungi 2
• Patients should avoid wearing contact lenses if they have signs or symptoms of bacterial conjunctivitis 2
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 4, 1

Patient Education

• Hand washing is important to reduce the risk of transmission 5
• Patients should avoid sharing towels, pillows, and close contact with others during the contagious period 5
• Patients can generally return to school or work once treatment has been initiated for 24 hours and symptoms begin to improve 5, 9