What is the treatment for conjunctivitis in a 20-month-old child?

Treatment of Conjunctivitis in a 20-Month-Old Child

For a 20-month-old with bacterial conjunctivitis, initiate topical fluoroquinolone antibiotics (such as levofloxacin or moxifloxacin) applied 4 times daily for 5-7 days, as this is the first-line treatment recommended for children older than 12 months. 1, 2

Initial Assessment and Red Flags

Before starting treatment, evaluate for features requiring immediate ophthalmology referral 3, 1:

• Visual loss or moderate to severe pain - requires urgent ophthalmology evaluation 3, 2
• Severe purulent discharge - obtain conjunctival cultures before treatment and consider gonococcal infection 1, 2
• Corneal involvement - immediate referral needed 3, 2
• Lack of response to therapy after 3-4 days - consider resistant organisms or alternative diagnosis 1, 4

Treatment Algorithm by Suspected Etiology

Mild to Moderate Bacterial Conjunctivitis (Most Common)

• Apply topical fluoroquinolone 4 times daily for 5-7 days 1, 2
• FDA-approved options for children >12 months include levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, and besifloxacin 1
• Alternative: polymyxin B/trimethoprim is also effective 2
• Topical antibiotics shorten symptom duration from 7 days (untreated) to 5 days (treated) 2

Gonococcal Conjunctivitis (If Suspected)

• Requires systemic antibiotic therapy in addition to topical treatment 1, 2, 4
• For children <45 kg: Ceftriaxone 125 mg IM single dose 2
• Daily follow-up until resolution is mandatory 2, 4
• Consider sexual abuse in all cases - reporting to authorities may be required 3, 2, 4

Chlamydial Conjunctivitis (If Suspected)

• Requires systemic antibiotic therapy; topical treatment alone is inadequate 3, 1, 2
• For children <45 kg: erythromycin base or ethylsuccinate 2
• No evidence supports adding topical therapy to systemic treatment 3
• Consider sexual abuse - appropriate reporting required 3, 2

Viral Conjunctivitis

• Supportive care only - no antibiotic therapy indicated 5, 6, 7
• Artificial tears, cold compresses, and antihistamine eye drops for symptom relief 6
• Contagious for 10-14 days from onset 3

Allergic Conjunctivitis

• Presents with bilateral itching and watery discharge 5, 7
• Topical antihistamines with mast cell-stabilizing activity are first-line 6, 7

Follow-Up and Monitoring

• Return for evaluation in 3-4 days if no improvement 1, 2, 4
• If symptoms persist despite appropriate treatment, consider 1, 2:
  • Alternative diagnoses (viral, allergic, foreign body)
  • Resistant organisms, particularly MRSA 1, 2, 4
  • Concurrent otitis media - consider internal ear examination 2

Infection Control and Return to Daycare/Activities

• Hand washing is crucial to reduce transmission 1, 2, 4
• Avoid sharing towels and pillows 1, 4
• Child can return to daycare/activities after 24 hours of treatment once symptoms begin improving 1, 2, 4
• Contagious period for viral conjunctivitis is typically 10-14 days 3

Common Pitfalls to Avoid

• Do not use topical corticosteroids without ophthalmology consultation - can worsen infectious causes 3
• Bacterial resistance is increasing, particularly MRSA - if no improvement after 3-4 days, consider culture and alternative antibiotics 1, 2, 4
• Do not miss gonococcal or chlamydial conjunctivitis - these require systemic therapy and consideration of sexual abuse 3, 1, 2
• Most cases of mild bacterial conjunctivitis are self-limited, resolving in 1-2 weeks without treatment 7, but antibiotics allow earlier return to activities 1, 2