Treatment for Bacterial Conjunctivitis
For mild bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily, with fluoroquinolones (moxifloxacin) or aminoglycosides (tobramycin) being first-line options. 1, 2, 3
Initial Treatment Approach
Mild Bacterial Conjunctivitis
- Administer a broad-spectrum topical antibiotic for 5-7 days, applied 4 times daily 1, 2, 3
- Choose the most convenient or least expensive option, as no clinical evidence suggests superiority of any particular antibiotic for mild cases 3
- This regimen accelerates clinical and microbiological remission by days 2-5, reduces transmissibility, and allows earlier return to school/work 1, 2
Recommended First-Line Antibiotics
- Fluoroquinolones (moxifloxacin, gatifloxacin, ofloxacin): Effective against common pathogens including Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pneumoniae 1, 2
- Aminoglycosides (tobramycin, gentamicin): Effective against many common bacterial pathogens 1, 2
- Alternative option: Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics when access to antibiotics is limited 1, 2, 3
Moderate to Severe Bacterial Conjunctivitis
Diagnostic Workup
- Obtain conjunctival cultures and Gram staining before initiating treatment, especially if gonococcal infection is suspected 1, 2, 3
- Look for copious purulent discharge, pain, and marked inflammation as indicators of severity 3
- Examine for swollen preauricular or submandibular lymph nodes 1
Treatment Modifications
- Guide antibiotic choice by laboratory test results 3
- Consider compounded topical antibiotics (vancomycin) for resistant organisms like MRSA 2, 3
Special Cases Requiring Systemic Therapy
Gonococcal Conjunctivitis
- Requires systemic antibiotic therapy rather than topical treatment alone 1, 2, 3
- Add saline lavage to promote comfort and faster resolution of inflammation 2
- Provide daily follow-up until resolution 3
- Hospitalization may be necessary for severe cases and is mandatory for neonatal conjunctivitis 2
Chlamydial Conjunctivitis
- Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 1, 2, 3
- No evidence supports additional topical therapy beyond systemic treatment 2
- For neonates: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses daily for 14 days 2
- Follow-up evaluation is important as treatment failure can occur in up to 19% of cases 3
Follow-Up and Monitoring
- Advise patients to return if no improvement after 3-4 days of treatment 1, 2
- Perform interval history, visual acuity measurement, and slit-lamp biomicroscopy at follow-up 1, 2
Critical Pitfalls to Avoid
Corticosteroid Use
- Avoid topical corticosteroids unless under close supervision, as they may prolong bacterial shedding and worsen infection 1
- If severe inflammation requires corticosteroids, perform baseline and periodic intraocular pressure measurements 2
Antibiotic Resistance
- Increasing bacterial resistance is a concern, particularly with MRSA 1, 2, 3
- Poor adherence to frequent administration regimens contributes to treatment failure 2
- For MRSA infections, vancomycin may be required 2
Contact Lens Wear
- Patients must not wear contact lenses if they have signs or symptoms of bacterial conjunctivitis 5, 4
Contamination Prevention
- Avoid contaminating the applicator tip by not allowing it to touch the eye, fingers, or other sources 5
When to Refer to Ophthalmology
Immediate referral is indicated for: 1, 2
- Visual loss
- Moderate or severe pain
- Severe purulent discharge
- Corneal involvement
- Conjunctival scarring
- Lack of response to therapy after 3-4 days
- Recurrent episodes
- Neonates (require prompt consultation, especially for HSV infection which can be life-threatening) 1