What is the recommended management for ocular infections and conjunctivitis?

Management of Ocular Infections and Conjunctivitis

Initial Differentiation and Treatment Strategy

For bacterial conjunctivitis, prescribe a 5-7 day course of topical broad-spectrum antibiotics, as this accelerates clinical resolution, reduces transmissibility, and allows earlier return to work or school, even in mild cases. 1, 2

The key to management is distinguishing bacterial from viral and allergic causes:

• Bacterial conjunctivitis presents with mattering and adherence of eyelids on waking, lack of itching, and no history of prior conjunctivitis 3
• Viral conjunctivitis (most common overall) is self-limited and does not require antibiotics; avoid indiscriminate antibiotic use 1, 3
• Allergic conjunctivitis is characterized by severe itching and allergen exposure; treat with topical antihistamines and mast cell stabilizers 1, 3

Antibiotic Selection for Bacterial Conjunctivitis

Choose topical fluoroquinolones (moxifloxacin 0.5% or ofloxacin) as first-line therapy for bacterial conjunctivitis, administered 3-4 times daily for 5-7 days. 2, 4, 5

Mild Bacterial Conjunctivitis

• Use the most convenient or least expensive broad-spectrum antibiotic, as no evidence demonstrates superiority of any particular agent 2
• WHO-endorsed options include topical gentamicin, tetracycline, or ofloxacin 1, 2
• Alternative options: polymyxin B/trimethoprim or erythromycin 2, 6

Moderate to Severe Bacterial Conjunctivitis

• Reserve fluoroquinolones for cases with copious purulent discharge, pain, and marked inflammation 2
• Obtain conjunctival cultures and Gram staining before initiating treatment 1, 2
• Contact lens wearers require fluoroquinolones due to higher risk of Pseudomonas infection 2, 4

Alternative When Antibiotics Are Limited

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics 2, 4

Special Situations Requiring Systemic Therapy

Gonococcal Conjunctivitis

Gonococcal conjunctivitis is a hyperacute, vision-threatening emergency requiring immediate systemic antibiotic therapy plus topical treatment and saline lavage. 1, 2

• Adults: Ceftriaxone 250 mg IM single dose 6
• Children <45 kg: Ceftriaxone 125 mg IM single dose 6
• Add topical antibiotics and frequent saline lavage 2
• Hospitalization may be necessary for severe cases; mandatory for neonates 2
• Consider sexual abuse in children with gonococcal conjunctivitis 2, 6

Chlamydial Conjunctivitis

Chlamydial conjunctivitis requires systemic antibiotics; topical therapy alone is insufficient. 1, 2

• Neonates: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses for 14 days (high cure rates: 96% clinical, 97% microbiological) 1, 2
• Children ≥8 years and adults: Azithromycin or doxycycline 6
• Consider sexual abuse in children with chlamydial conjunctivitis 2, 6

Trachoma

• Single-dose oral azithromycin or 1 week of oral tetracycline for adults 1

Viral Conjunctivitis Management

Viral conjunctivitis (primarily adenoviral) requires no antibiotics; focus on patient education about contagion control and symptomatic relief. 1

Patient Education and Infection Control

• Educate about 10-14 day contagious period from onset 1
• Instruct on frequent handwashing, separate towels/pillows, and avoiding close contact 1, 4
• Disinfect tonometers with 1:10 dilute bleach solution; 70% isopropyl alcohol is no longer recommended 1

Symptomatic Treatment

• Artificial tears, topical antihistamines, cold compresses, or oral analgesics 1
• Avoid antibiotics to prevent adverse effects and resistance 1

Topical Corticosteroids (Selective Use)

• Reserve for severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis 1
• Use fluorometholone, rimexolone, or loteprednol to minimize IOP elevation and cataract risk 1
• Monitor IOP and perform pupillary dilation periodically during prolonged use 1
• Taper slowly once inflammation is controlled 1
• Note: Corticosteroids may prolong viral shedding in animal models 1

Emerging Therapies Under Investigation

• Povidone-iodine 0.4-0.6% with or without dexamethasone 0.1% shows promise for reducing viral titers and shortening clinical course 1
• Off-label topical ganciclovir 0.15% gel may benefit specific adenovirus serotypes but requires further study 1

Allergic Conjunctivitis Management

Treat allergic conjunctivitis with topical antihistamines and mast cell stabilizers; reserve corticosteroids for severe vernal conjunctivitis exacerbations. 1, 3

• Itching is the most consistent sign distinguishing allergic from infectious causes 3, 7
• For acute exacerbations of vernal conjunctivitis, topical corticosteroids are usually necessary to control severe symptoms 1

Follow-Up and Referral Guidelines

When to Schedule Follow-Up

• Advise patients to return if no improvement after 3-4 days of treatment 2, 4, 6
• Patients with severe disease, corneal epithelial ulceration, or membranous conjunctivitis should be re-evaluated within 1 week 1
• Perform interval history, visual acuity measurement, and slit-lamp biomicroscopy at follow-up 2

When to Refer to Ophthalmology

Refer immediately to an ophthalmologist for visual loss, moderate or severe pain, severe purulent discharge, corneal involvement, conjunctival scarring, lack of response to therapy, or recurrent episodes. 2, 6

• Contact lens wearers with bacterial conjunctivitis require ophthalmology referral due to higher complication risk 6
• Consider internal ear examination in children with acute bacterial conjunctivitis, as concurrent otitis media is common 6

Critical Pitfalls and Resistance Concerns

Antibiotic Resistance

• MRSA is increasingly isolated and resistant to many commercially available topical antibiotics; may require compounded topical vancomycin 2, 4
• Pseudomonas aeruginosa resistance to moxifloxacin increased from 19% to 52% in southern India (2007-2009) 4
• Gram-negative conjunctivitis in neonatal intensive care settings is often resistant to gentamicin 2
• To prevent resistance, use intermittent treatment courses with different antibiotic mechanisms of action 2

Common Errors to Avoid

• Do not prescribe antibiotics for viral conjunctivitis—this increases costs and promotes resistance 2
• Do not use topical antibiotics alone for gonococcal or chlamydial conjunctivitis—systemic therapy is mandatory 2, 6
• Patients should not wear contact lenses during bacterial conjunctivitis treatment 5
• Poor adherence to frequent dosing regimens contributes to treatment failure 4, 8