What is the treatment for pediatric bacterial conjunctivitis?

Treatment of Pediatric Bacterial Conjunctivitis

Topical fluoroquinolone antibiotics are the first-line treatment for pediatric bacterial conjunctivitis, administered 4 times daily for 5-7 days. 1

First-Line Treatment Options

• FDA-approved topical fluoroquinolones for children older than 12 months include levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, and besifloxacin 1
• For bacterial conjunctivitis, ciprofloxacin dosage is one or two drops instilled into the conjunctival sac every two hours while awake for two days, then one or two drops every four hours while awake for the next five days 2
• Broad-spectrum topical antibiotics accelerate clinical and microbiological remission, reduce transmissibility, and allow earlier return to school 3

Treatment Algorithm Based on Severity

Mild to Moderate Bacterial Conjunctivitis

• Apply topical antibiotic 4 times daily for 5-7 days 1
• Most cases can be treated effectively in an outpatient setting 4
• Advise parents to return with the child for evaluation in 3-4 days if no improvement is noted 1, 3

Severe Bacterial Conjunctivitis

• Consider obtaining conjunctival cultures before starting treatment if severe purulent discharge is present 1, 3
• For cases with vision loss, severe pain, or corneal involvement, refer to an ophthalmologist 1, 5
• Haemophilus influenzae and Streptococcus pneumoniae are the most common pathogens in pediatric bacterial conjunctivitis 6, 7

Special Considerations for Specific Infections

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy in addition to topical treatment 4, 3
• Saline lavage may promote comfort and more rapid resolution of inflammation 4
• Daily follow-up is required until resolution 4
• Sexual abuse should be considered in children with this condition 4, 5

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites (nasopharynx, genital tract, lungs) 4, 5
• No evidence supports additional topical therapy beyond systemic treatment 4
• Sexual abuse should be considered in children with this condition 4, 5
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 4

Follow-Up Recommendations

• Return for evaluation if no improvement after 3-4 days of treatment 4, 1, 3
• For gonococcal conjunctivitis, daily follow-up until resolution is necessary 4
• At follow-up visits, perform interval history, visual acuity measurement, and slit-lamp biomicroscopy 4, 3

Patient Education and Prevention

• Strict hand washing to reduce the risk of transmission 1, 5
• Avoid sharing towels and close contact with others during the contagious period 1, 5
• Children can generally return to school once treatment has been initiated for 24 hours and symptoms begin to improve 1

Common Pitfalls and Caveats

• Bacterial resistance is a growing concern, particularly with MRSA infections, which may require alternative antibiotics such as vancomycin 4, 3
• Failure to consider gonococcal or chlamydial infection in infants, which requires systemic treatment 3, 5
• Not considering the possibility of child abuse in cases of potentially sexually transmitted ocular disease in children 5
• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 5

When to Refer to an Ophthalmologist

• Visual loss, moderate or severe pain, severe purulent discharge 4, 3, 5
• Corneal involvement, conjunctival scarring 4, 5
• Lack of response to therapy after 3-4 days 4, 1, 3
• Recurrent episodes, history of HSV eye disease, or history of immunocompromise 4, 5