What is the treatment protocol for conjunctivitis?

Treatment Protocol for Conjunctivitis

Bacterial Conjunctivitis

For mild to moderate bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily, which accelerates clinical resolution, reduces transmissibility, and allows earlier return to school or work. 1

First-Line Antibiotic Selection

• Choose the most convenient or least expensive broad-spectrum topical antibiotic for mild cases, as no clinical evidence demonstrates superiority of any particular agent 1

• Acceptable first-line options include:

  • Polymyxin B/trimethoprim 1
  • Gentamicin 1
  • Tobramycin 1
  • Erythromycin 1

• Reserve fluoroquinolones (moxifloxacin, gatifloxacin, levofloxacin, ciprofloxacin, besifloxacin) for moderate to severe cases with copious purulent discharge, pain, and marked inflammation, or when resistant organisms are suspected 1

• Contact lens wearers require fluoroquinolone coverage due to higher risk of Pseudomonas infection 1

Dosing Regimens

• Standard regimen: Apply topical antibiotic 4 times daily for 5-7 days 1, 2
• Moxifloxacin 0.5%: Instill one drop in affected eye 3 times daily for 7 days 3
• Moxifloxacin demonstrates clinical cure rates of 66-69% by Day 5-6 and microbiological eradication rates of 84-94% 3

Moderate to Severe Bacterial Conjunctivitis

• Obtain conjunctival cultures and Gram staining before initiating treatment if severe purulent discharge is present or gonococcal infection is suspected 1
• Consider brief course of topical corticosteroids if severe inflammation of conjunctiva or eyelid is present, with baseline and periodic intraocular pressure monitoring 1

Follow-Up Protocol

• Advise patients to return in 3-4 days if no improvement is noted 4, 1
• At follow-up, perform interval history, visual acuity measurement, and slit-lamp biomicroscopy 1
• If no improvement after 3-4 days, consider alternative diagnoses, resistant organisms (particularly MRSA), or need for culture 1

Special Bacterial Conjunctivitis Scenarios

Gonococcal Conjunctivitis

Gonococcal conjunctivitis requires systemic antibiotic therapy in addition to topical treatment, as topical antibiotics alone are inadequate. 1

• Systemic treatment: Ceftriaxone 125 mg IM single dose (for patients ≥45 kg) 2
• Add saline lavage to promote comfort and faster resolution of inflammation 1
• Daily follow-up is mandatory until resolution 2
• Hospitalization may be necessary for severe cases 1
• Always consider and evaluate for sexual abuse in children with gonococcal conjunctivitis 2
• Treat sexual partners simultaneously 4

Chlamydial Conjunctivitis

Chlamydial conjunctivitis requires systemic antibiotic therapy, as more than 50% of infants may have infection at other sites (nasopharynx, genital tract, lungs). 4

• Systemic treatment options (for patients ≥8 years):
  • Azithromycin 1 g orally, single dose, OR 2
  • Doxycycline 100 mg orally twice daily for 7 days 2
• For neonates: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into four doses daily for 14 days 1
• No evidence supports adding topical therapy to systemic treatment 4, 1
• Re-evaluate following treatment, as treatment failure rates can reach 19% 4
• Treat sexual partners simultaneously and evaluate for concomitant sexually transmitted diseases 4
• Consider sexual abuse in children with chlamydial conjunctivitis 4, 2

MRSA Conjunctivitis

• MRSA infections may require compounded topical vancomycin, as MRSA organisms are resistant to many commercially available topical antibiotics including aminoglycosides 1
• Bacterial resistance is an increasing concern, particularly with MRSA 1, 5

Neonatal Conjunctivitis (Birth to 28 Days)

Neonatal conjunctivitis always requires immediate treatment and evaluation due to risk of serious complications including corneal perforation, septicemia, and meningitis. 5

• Hospitalization is mandatory for neonatal conjunctivitis 1
• Gonococcal conjunctivitis (manifests 1-7 days after birth) requires systemic ceftriaxone 125 mg IM plus topical antibiotics 5

Viral Conjunctivitis

Viral conjunctivitis requires supportive treatment only; avoid prescribing antibiotics as this promotes unnecessary costs and antibiotic resistance. 1, 6

• Treatment is supportive with artificial tears and cool compresses 6
• Most cases are self-limiting 6

Allergic Conjunctivitis

Allergic conjunctivitis is treated with topical antihistamines and mast cell stabilizers; itching is the most consistent diagnostic sign. 6

• Treatment options include:
  • Topical lubricants 7
  • Topical antihistamine agents 7
  • Systemic antihistamines 7

Mandatory Ophthalmology Referral Criteria

Refer to an ophthalmologist immediately for any of the following: 4, 1

• Visual loss 4, 1
• Moderate or severe pain 4, 1
• Severe purulent discharge 4, 1
• Corneal involvement or infiltrates 4, 1, 5
• Conjunctival scarring 4
• Lack of response to therapy after 3-4 days 4, 1
• Recurrent episodes 4
• History of HSV eye disease 4
• History of immunocompromise 4
• All contact lens wearers with conjunctivitis due to higher risk of complications 2

Infection Control and Patient Education

• Hand washing is critical to reduce transmission risk 4, 5
• Avoid sharing towels, pillows, and close contact during contagious period 2
• Patients should not wear contact lenses if signs or symptoms of bacterial conjunctivitis are present 4, 3
• Return to school or work is generally permitted once treatment has been initiated for 24 hours and symptoms begin to improve 5, 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral conjunctivitis, which promotes resistance and unnecessary costs 1
• Do not use topical antibiotics alone for gonococcal or chlamydial conjunctivitis—systemic therapy is mandatory 1, 2
• Do not overlook the possibility of sexual abuse in children with gonococcal or chlamydial infections 4, 2
• Do not use fluoroquinolones as first-line for mild cases—reserve for severe infections to minimize resistance 1
• In neonatal intensive care settings, gram-negative conjunctivitis is often resistant to gentamicin 1