Treatment of Bacterial Conjunctivitis
For mild bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily, which accelerates clinical resolution and reduces transmissibility. 1, 2
Mild Bacterial Conjunctivitis
Treatment approach:
- Initiate a 5-7 day course of any broad-spectrum topical antibiotic applied 4 times daily 1, 2
- Choose the most convenient or least expensive option, as no specific antibiotic has proven superiority for uncomplicated cases 2
- While mild cases are self-limited and may resolve spontaneously, topical antibiotics shorten symptom duration from approximately 4-5 days to 2-3 days and allow earlier return to school or work 1, 3
Effective antibiotic options include:
- Fluoroquinolones (moxifloxacin, gatifloxacin, ciprofloxacin) - effective against common pathogens including S. aureus, H. influenzae, and S. pneumoniae 1, 4, 5
- Aminoglycosides (tobramycin, gentamicin) - effective against many common bacterial pathogens 1, 4
- Azithromycin - dosed twice daily for 2 days, then once daily for 5 days 6
- Polymyxin B/trimethoprim - alternative option 1
- Povidone-iodine 1.25% ophthalmic solution - may be as effective as antibiotics when access is limited 1, 2
Key clinical features suggesting bacterial (not viral) conjunctivitis:
- Mattering and adherence of eyelids on waking 7
- Purulent discharge 8, 4
- Lack of itching 7
- No history of recurrent conjunctivitis 7
Moderate to Severe Bacterial Conjunctivitis
Characterized by copious purulent discharge, pain, and marked inflammation 8, 2
Management approach:
- Obtain conjunctival cultures and Gram staining before initiating treatment 8, 1
- Guide antibiotic choice based on laboratory results 8
- Consider MRSA, which shows increasing prevalence and resistance to many topical antibiotics - may require compounded vancomycin 8, 1, 2
Special Situations Requiring Systemic Therapy
Gonococcal Conjunctivitis
Requires systemic antibiotics - topical therapy alone is insufficient 8, 1, 4
- Obtain cultures and Gram staining immediately 8
- Initiate systemic therapy before culture results if high clinical suspicion 8
- Add saline lavage for comfort and faster resolution 8, 1
- Treat topically as for bacterial keratitis if corneal involvement present 8
- Follow daily until resolution with interval history, visual acuity, and slit-lamp examination 8
- Rule out N. meningitidis before concluding N. gonorrhoeae is responsible 8
- Evaluate and treat sexual contacts; consider sexual abuse in children 8, 4
Chlamydial Conjunctivitis
Requires systemic antibiotics - topical therapy provides no additional benefit 8, 1, 4
- Systemic therapy is mandatory in infants, as >50% have infection at other sites (nasopharynx, genital tract, lungs) 8
- Treatment failure occurs in up to 19% of cases - re-evaluate following treatment 8
- Evaluate and treat sexual contacts; consider sexual abuse in children 8, 4
Follow-Up and Referral
Advise patients to return in 3-4 days if no improvement 8, 1, 4
Refer to ophthalmology for:
- Visual loss 1, 4
- Moderate or severe pain 1, 4
- Severe purulent discharge 1, 4
- Corneal involvement 1, 4
- Conjunctival scarring 1, 4
- Lack of response to therapy 1, 4
- Recurrent episodes 1, 4
Critical Pitfalls to Avoid
- Do not use topical corticosteroids unless under ophthalmology supervision, as they may prolong bacterial shedding and worsen infection 4
- Increasing MRSA resistance is a growing concern - consider culture-guided therapy for treatment failures 8, 1, 9
- Poor adherence to frequent dosing regimens contributes to treatment failure and resistance 1, 9
- Always consider gonococcal or chlamydial infection in neonates and sexually active patients, as these require systemic therapy 8, 1
- Screen for sexual abuse in children with gonococcal or chlamydial conjunctivitis 8, 4, 2