Treatment of Bacterial Conjunctivitis in Children
First-Line Treatment
Topical fluoroquinolone antibiotics administered 4 times daily for 5-7 days are the recommended first-line treatment for bacterial conjunctivitis in children older than 12 months. 1, 2
- FDA-approved fluoroquinolones for children >12 months include levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, and besifloxacin 2
- Polymyxin B/trimethoprim is an effective alternative option with broad-spectrum coverage 1, 3
- Topical antibiotics reduce symptom duration from 7 days (untreated) to 5 days (treated) and allow earlier return to school 1, 4
Dosing for Ciprofloxacin (FDA-Approved Regimen)
- Instill 1-2 drops into the conjunctival sac every 2 hours while awake for 2 days 5
- Then 1-2 drops every 4 hours while awake for the next 5 days 5
Treatment Algorithm by Severity
Mild to Moderate Cases
- Apply topical antibiotic 4 times daily for 5-7 days 2
- No cultures needed for uncomplicated cases 1
- Follow up in 3-4 days if no improvement 2, 6
Severe Cases (Copious Purulent Discharge, Marked Inflammation)
- Obtain conjunctival cultures and Gram staining before starting treatment 2, 6
- Reserve fluoroquinolones (ofloxacin, ciprofloxacin) for these cases 6
- Immediate ophthalmology referral required for visual loss, moderate/severe pain, corneal involvement, or severe purulent discharge 1, 2
Special Pathogen Considerations
Gonococcal Conjunctivitis
Requires systemic antibiotic therapy in addition to topical treatment—topical therapy alone is insufficient. 1, 2, 6
- Ceftriaxone 125 mg IM for children <45 kg 1
- Ceftriaxone 250 mg IM for children ≥45 kg 1
- Daily follow-up until resolution 1, 2
- Consider sexual abuse in any child with gonococcal conjunctivitis and report to appropriate authorities 1, 2
Chlamydial Conjunctivitis
Requires systemic antibiotic therapy—topical treatment alone is inadequate. 1, 2, 6
- Erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses for 14 days (children <45 kg) 1, 6
- Azithromycin or doxycycline for children ≥8 years old 1
- Consider sexual abuse and report appropriately 1, 6
MRSA Conjunctivitis
- Bacterial resistance is an increasing concern, particularly with methicillin-resistant S. aureus 1, 2, 6
- May require alternative antibiotics such as compounded topical vancomycin 2, 6
Return to School and Infection Control
- Children can return to school once treatment has been initiated for 24 hours and symptoms begin to improve 1, 2
- Hand washing is crucial to reduce transmission risk 1, 2
- Avoid sharing towels and close contact during the contagious period 2
When to Refer to Ophthalmology
Immediate referral is required for: 1, 2, 6
- Visual loss
- Moderate or severe pain
- Corneal involvement
- Severe purulent discharge
- Lack of response to therapy after 3-4 days
- Recurrent episodes
Important Caveats
- Examine ears in children with bacterial conjunctivitis, as concurrent otitis media is common 1
- Contact lens wearers should be referred to ophthalmology due to higher risk of Pseudomonas infection and complications 1, 6
- Poor adherence to frequent administration regimens contributes to treatment failure 6, 7
- The most common bacterial pathogens are Haemophilus influenzae (44-54%) and Streptococcus pneumoniae (14-31%) 8, 9