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 to Moderate Bacterial Conjunctivitis

• Topical antibiotics are recommended even for mild cases as they reduce symptom duration and improve clinical outcomes 1
• Apply broad-spectrum topical antibiotic 4 times daily for 5-7 days 2
• Common antibiotic options include:
  • Fluoroquinolones (e.g., ciprofloxacin): 1-2 drops every 2 hours while awake for 2 days, then 1-2 drops every 4 hours while awake for 5 days 3
  • Azithromycin: 1 drop twice daily (8-12 hours apart) for the first 2 days, then once daily for 5 days 4
  • Other options: gentamicin, tetracycline, ofloxacin, moxifloxacin, gatifloxacin 1
• Patients should return for follow-up if no improvement after 3-4 days of treatment 1, 2

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, 2
• The choice of antibiotic should be guided by laboratory test results 5
• For MRSA infections, compounded topical antibiotics such as vancomycin may be required 1, 2

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 1, 2
• Saline lavage may promote comfort and faster resolution of inflammation 5
• Daily follow-up until resolution of conjunctivitis is necessary 5
• If corneal involvement is present, treat as bacterial keratitis 5

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 1
• Follow-up evaluation is important as treatment failure can occur in up to 19% of cases 5
• No evidence supports additional topical therapy beyond systemic treatment 1

Alternative Treatment Options

• 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
• This option is particularly useful in developing countries with limited antibiotic access 5

Common Pathogens and Antibiotic Selection

• Most common pathogens include Haemophilus influenzae (44.8%), Streptococcus pneumoniae (30.6%), Staphylococcus aureus (7.5%), and Moraxella species 6
• Ciprofloxacin, chloramphenicol, and rifampin have shown good activity against these common pathogens 6
• Increasing bacterial resistance is a concern, particularly with MRSA 1, 2

Important Caveats and Pitfalls

• While bacterial conjunctivitis is often self-limiting, topical antibiotics shorten the duration of clinical disease and enhance eradication of the causative organism 7
• Never use topical corticosteroids unless the conjunctivitis is proven to be nonherpetic 8
• For children with gonococcal or chlamydial infections, consider the possibility of sexual abuse 1, 2
• Poor adherence to prescribed regimens can contribute to treatment failure and bacterial resistance 9
• Skipping doses or not completing the full course of therapy may decrease treatment effectiveness and increase the likelihood of bacterial resistance 4