What is the recommended treatment for bacterial conjunctivitis?

Treatment of Bacterial Conjunctivitis

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

Treatment Based on Severity

Mild Bacterial Conjunctivitis

• A 5-7 day course of broad-spectrum topical antibiotic is recommended as it accelerates clinical and microbiological remission in days 2-5 of treatment 2, 1
• Treatment reduces transmissibility and allows earlier return to school/work 2, 1
• While mild bacterial conjunctivitis may resolve spontaneously, antibiotics shorten the duration of symptoms 2
• The choice of antibiotic is usually empiric, with no evidence suggesting superiority of any particular antibiotic 2

Moderate to Severe Bacterial Conjunctivitis

• Characterized by copious purulent discharge, pain, and marked inflammation 2, 3
• Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 2, 1
• The choice of antibiotic should be guided by laboratory test results 2

Recommended Antibiotics

• Fluoroquinolones (e.g., moxifloxacin, gatifloxacin) are effective against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae 4, 5
• Aminoglycosides like tobramycin are also effective options 1, 6
• For areas with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 2, 1

Special Considerations

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy rather than topical treatment alone 2, 1
• Saline lavage may promote comfort and faster resolution of inflammation 2
• Patients should be seen daily until resolution 2
• Sexual contacts should be informed and referred appropriately 2

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 2, 1
• No evidence supports additional topical therapy beyond systemic treatment 1
• Re-evaluation following treatment is necessary due to potential treatment failure (up to 19%) 2

Methicillin-Resistant Staphylococcus aureus (MRSA)

• MRSA has been isolated with increasing frequency from patients with bacterial conjunctivitis 2
• MRSA organisms are resistant to many commercially available topical antibiotics 2
• Microbiology laboratory testing may guide therapy, which may include compounded topical antibiotics such as vancomycin 2, 1

Follow-up Recommendations

• Patients should be advised to return for follow-up if no improvement is seen after 3-4 days of treatment 2, 3
• Follow-up should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 2, 3

Important Considerations and Pitfalls

• Avoid using topical corticosteroids unless under close supervision, as they may worsen infection 3
• Bacterial resistance is a growing concern, particularly with MRSA infections 1, 7
• For children with gonococcal or chlamydial infections, consider the possibility of sexual abuse 2, 1
• Poor adherence to frequent administration regimens can contribute to treatment failure 7
• Advise patients about hygiene measures to prevent spread, such as frequent hand washing and avoiding sharing of personal items 3, 6

When to Refer to an Ophthalmologist

• Visual loss, moderate or severe pain, severe purulent discharge 1, 3
• Corneal involvement, conjunctival scarring 1, 3
• Lack of response to therapy or recurrent episodes 1, 3