What is the recommended management for infantile conjunctivitis (pink eye)?

Management of Infantile Pink Eye (Conjunctivitis)

For bacterial conjunctivitis in infants, topical broad-spectrum antibiotic therapy applied 4 times daily for 5-7 days is the recommended first-line treatment, with erythromycin 0.5% ophthalmic ointment being the standard agent. 1, 2, 3

Initial Assessment and Red Flags

Before initiating treatment, immediately refer to ophthalmology if any of the following are present:

• Visual loss or moderate to severe pain 1, 2
• Corneal involvement or severe purulent discharge 1, 2
• Conjunctival scarring or recurrent episodes 2
• History of immunocompromise 2

Treatment Algorithm Based on Clinical Presentation

Uncomplicated Bacterial Conjunctivitis

• Apply erythromycin 0.5% ophthalmic ointment as a 1 cm ribbon into the lower conjunctival sac 4-6 times daily for 5-7 days 3, 4
• Alternative options include polymyxin B-bacitracin or polymyxin B-trimethoprim ointments 3
• Topical antibiotics reduce symptom duration from 7 days (untreated) to 5 days (treated) 1
• Antibiotic treatment is critical in neonates to prevent secondary bacterial corneal ulceration 5

Gonococcal Conjunctivitis (Severe Purulent Discharge)

This requires immediate systemic therapy in addition to topical treatment:

• Obtain conjunctival cultures and Gram stain before treatment 5
• Administer Ceftriaxone 125 mg IM for infants weighing less than 45 kg 1
• Add topical erythromycin ointment (though systemic therapy is primary) 5
• Daily follow-up is mandatory until complete resolution 5, 1
• Saline lavage may promote comfort and faster resolution 5
• Consider sexual abuse in all cases 1, 2

Chlamydial Conjunctivitis (Persistent Follicular Pattern)

Systemic antibiotics are mandatory because topical therapy alone is inadequate:

• Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses for 14 days 5, 3
• More than 50% of infants have concurrent infection at other sites (nasopharynx, genital tract, lungs) 2
• Topical antibiotics are unnecessary when systemic treatment is given 5
• Treatment efficacy is approximately 80%; a second course may be required 5
• Follow-up is essential to confirm treatment success 5
• Consider sexual abuse in all cases 1, 2

Critical Supportive Measures

• Strict hand hygiene is essential to prevent transmission to the unaffected eye or others 2, 3
• Avoid sharing towels or close contact during the contagious period 2
• Preservative-free artificial tears can provide additional comfort 2

Common Pitfalls to Avoid

• Do not use topical antibiotics alone for gonococcal or chlamydial conjunctivitis—systemic therapy is mandatory 5, 2
• Avoid indiscriminate use of topical corticosteroids 2
• Do not miss the "conjunctivitis-otitis syndrome"—examine ears in infants with bacterial conjunctivitis, as concurrent otitis media is common 1, 6
• Always consider sexual abuse when gonococcal or chlamydial infection is diagnosed in an infant 1, 2

Follow-Up Protocol

• Return for evaluation if no improvement after 3-4 days of treatment 1, 2
• For gonococcal conjunctivitis, daily visits are required until resolution 5, 1
• For chlamydial conjunctivitis, re-evaluate after completing therapy due to 19% treatment failure rate 5
• Consider resistant organisms (particularly MRSA) if symptoms persist despite appropriate treatment 1, 3

Special Considerations

• Infants requiring systemic treatment are best managed in conjunction with a pediatrician 2
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 5, 2
• Mothers and sexual partners of infants with gonococcal or chlamydial infection must be evaluated and treated 5, 7
• Gram-negative organisms resistant to gentamicin are increasingly common in low birth weight/premature infants in neonatal intensive care settings 5