What is the treatment for conjunctivitis (pink eye) in a 3-year-old child?

Treatment of Pink Eye in a 3-Year-Old

For a 3-year-old with bacterial conjunctivitis, initiate a 5-7 day course of broad-spectrum topical antibiotic (such as polymyxin B/trimethoprim or erythromycin ophthalmic ointment) applied 4 times daily. 1, 2

Initial Assessment and Red Flags

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

• Visual loss or decreased vision 1, 2
• Moderate to severe eye pain 1, 2
• Severe purulent discharge (suggests possible gonococcal infection) 1, 3
• Corneal involvement (opacity, infiltrate, or ulcer) 4, 1
• History of immunocompromise 2

First-Line Antibiotic Treatment

Topical antibiotic options for uncomplicated bacterial conjunctivitis:

• Polymyxin B/trimethoprim drops: Apply 4 times daily for 5-7 days 1, 5
• Erythromycin ophthalmic ointment: Apply approximately 1 cm ribbon to affected eye(s) up to 6 times daily depending on severity 6
• Fluoroquinolone drops (for children >12 months): Apply 4 times daily for 5-7 days 1

Topical antibiotics reduce symptom duration from 7 days (untreated) to 5 days (treated) and allow earlier return to school. 1, 7

Special Circumstances Requiring Systemic Treatment

Gonococcal Conjunctivitis

If severe purulent discharge with rapid onset suggests gonococcal infection:

• Ceftriaxone 125 mg IM single dose (for children <45 kg) 1, 3
• Daily follow-up until resolution is mandatory 1, 3
• Consider sexual abuse and report to appropriate authorities 1, 3
• Obtain conjunctival cultures before treatment 3

Chlamydial Conjunctivitis

If follicular conjunctivitis or chronic symptoms suggest chlamydia:

• Erythromycin base or ethylsuccinate 30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks 4, 1
• Systemic treatment is essential as >50% have nasopharyngeal, genital, or pulmonary co-infection 2
• Consider sexual abuse in children with this diagnosis 4, 1

Supportive Care Measures

• Preservative-free artificial tears for symptom relief and to avoid additional irritation 2
• Strict hand hygiene to prevent transmission to others or the unaffected eye 2, 3
• Avoid sharing towels, pillows, or close contact during contagious period 3
• Cold compresses for comfort 8

Return to School/Daycare

Children can return to school once treatment has been initiated for 24 hours and symptoms begin to improve. 1, 3

Follow-Up and Treatment Failure

• Return for evaluation if no improvement after 3-4 days of treatment 1, 2, 3
• Consider alternative diagnoses (viral conjunctivitis, allergic conjunctivitis, foreign body) 9, 8
• Consider resistant organisms, particularly methicillin-resistant S. aureus (MRSA) 3
• Obtain conjunctival cultures if not previously done 3

Common Pitfalls to Avoid

• Do not use topical corticosteroids without ophthalmology consultation, as they can worsen herpes simplex virus infections 4
• Do not assume all conjunctivitis is bacterial - viral conjunctivitis (more common in adults) requires only supportive care 8, 10
• Do not miss gonococcal or chlamydial infection in children, which requires systemic antibiotics 2, 3
• Do not fail to consider child abuse when sexually transmitted infections are diagnosed 4, 1

When Viral or Allergic Conjunctivitis is More Likely

Viral conjunctivitis features:

• Watery discharge (not purulent) 8, 10
• Burning, gritty sensation 9
• Often bilateral with preauricular lymphadenopathy 4
• Treatment is supportive only - no antibiotics needed 8, 10

Allergic conjunctivitis features:

• Bilateral itching (most consistent sign) 10
• Watery discharge 8
• Seasonal pattern 9
• Treat with topical antihistamines/mast cell stabilizers, not antibiotics 8, 10