What is the recommended treatment for bacterial conjunctivitis?

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 antibiotics 4 times daily for 5-7 days, using the most convenient or least expensive option as there is no clinical evidence suggesting superiority of any particular antibiotic 2
• Topical antibiotics are recommended even in mild cases as they reduce symptom duration and improve clinical outcomes 1
• While mild bacterial conjunctivitis may resolve spontaneously in immunocompetent adults, treatment accelerates recovery and reduces transmission 2

Moderate to Severe Bacterial Conjunctivitis

• Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 1, 2
• For severe cases with vision loss, severe pain, or corneal involvement, referral to an ophthalmologist is recommended 3
• More aggressive treatment approaches are needed for cases characterized by copious purulent discharge, pain, and marked inflammation 2

Recommended Antibiotics

• The World Health Organization endorses topical gentamicin, tetracycline, and ofloxacin for bacterial conjunctivitis 1
• Fluoroquinolones (e.g., moxifloxacin, gatifloxacin) are effective against common pathogens 1
• Gatifloxacin ophthalmic solution 0.5% is FDA-approved for bacterial conjunctivitis caused by susceptible strains of common pathogens including Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Haemophilus influenzae 4
• For gatifloxacin, the recommended dosage is one drop every two hours while awake (up to 8 times) on Day 1, then one drop 2-4 times daily on Days 2-7 4
• Ciprofloxacin, chloramphenicol, and rifampin have shown good activity against the most prevalent pathogens (H. influenzae and S. pneumoniae) 5

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 1
• Saline lavage should be added to promote comfort and faster resolution of inflammation 1
• Daily follow-up is recommended until resolution 3

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 1
• 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
• No evidence supports additional topical therapy beyond systemic treatment 1

MRSA Infections

• For methicillin-resistant S. aureus (MRSA) infections, vancomycin may be required 1
• Compounded topical antibiotics may be necessary in cases of resistant organisms 2

Follow-up Care and Patient Education

• Patients should return for evaluation if no improvement is seen after 3-4 days of treatment 3, 2
• Hand washing is crucial to reduce transmission risk 3
• Patients should avoid sharing towels, pillows, and close contact with others during the contagious period 3
• Patients can generally return to school or work once treatment has been initiated for 24 hours and symptoms begin to improve 3
• Contact lens wear should be avoided during the course of treatment 4

Common Pitfalls and Caveats

• Bacterial resistance is a growing concern, particularly with MRSA infections 1, 6
• Poor adherence to frequent administration regimens can contribute to treatment failure 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Prolonged use of antibiotics may result in overgrowth of nonsusceptible organisms, including fungi 4
• For conjunctivitis in neonates, immediate referral to an ophthalmologist is indicated 7