What is the recommended treatment order for a patient with conjunctivitis?

Treatment Order for Conjunctivitis

Initial Assessment and Triage

The treatment approach for conjunctivitis depends critically on identifying the etiology—viral, bacterial, allergic, or other causes—through clinical presentation, as this determines whether antibiotics, supportive care, or anti-inflammatory agents are indicated. 1

Key Clinical Differentiators

• Bacterial conjunctivitis: Look for mucopurulent discharge, mattering and adherence of eyelids on waking, lack of itching, and no history of recurrent conjunctivitis 2
• Viral conjunctivitis: Variable presentation, watery discharge, often associated with upper respiratory symptoms, highly contagious 1
• Allergic conjunctivitis: Itching is the most consistent and prominent symptom, bilateral presentation, history of atopy 2, 3

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Treatment Algorithm by Etiology

Mild Bacterial Conjunctivitis

For uncomplicated mild bacterial conjunctivitis in immunocompetent patients, initiate empiric broad-spectrum topical antibiotic therapy, with moxifloxacin 0.5% three times daily for 5-7 days as the preferred first-line agent due to superior efficacy and faster symptom resolution. 4, 5

• Moxifloxacin 0.5% demonstrates clinical cure rates of 66-69% by day 5-6 and microbiological eradication rates of 84-94%, with 81% complete resolution by 48 hours 6, 5
• Alternative options include other fluoroquinolones or polymyxin B/trimethoprim, though the latter shows significantly slower resolution (44% at 48 hours vs. 81% with moxifloxacin) 5
• In resource-limited settings, povidone-iodine 1.25% ophthalmic solution may be considered as an effective alternative 1, 4
• Instruct patients to return in 3-4 days if no improvement occurs 4, 7

Moderate to Severe Bacterial Conjunctivitis

Moderate to severe bacterial conjunctivitis requires immediate empiric broad-spectrum topical antibiotic therapy with consideration for culture and sensitivity testing to guide treatment, particularly if initial therapy fails. 1, 7

• Consider culture before initiating therapy in severe cases with copious purulent discharge, corneal involvement, or immunocompromised patients 7
• Be aware of increasing resistance patterns: Pseudomonas aeruginosa resistance to moxifloxacin reached 52% in some regions, and MRSA shows resistance to many topical antibiotics 4
• For suspected MRSA not responding to fluoroquinolones, refer for possible vancomycin therapy 4

Gonococcal Conjunctivitis (Hyperacute)

Gonococcal conjunctivitis is a vision-threatening emergency requiring immediate systemic antibiotic therapy in addition to topical treatment. 1

Adults

• Ceftriaxone 1 g IM single dose PLUS azithromycin 1 g orally single dose (to cover concurrent chlamydial infection) 1
• Alternative if ceftriaxone unavailable: Cefixime 400 mg orally single dose 1
• Consider saline lavage of infected eye 1

Children

• Weight ≤45 kg: Ceftriaxone 25-50 mg/kg IV or IM single dose (not to exceed 250 mg) 1
• Weight >45 kg: Same as adult dosing 1

Neonates (Ophthalmia Neonatorum)

• Ceftriaxone 25-50 mg/kg IV or IM single dose (not to exceed 250 mg) 1
• Requires immediate pediatric consultation as systemic infection is life-threatening 1
• Prophylaxis at birth: Erythromycin 0.5% ophthalmic ointment single application 1

Chlamydial Conjunctivitis

Chlamydial conjunctivitis requires systemic antibiotic therapy as topical treatment alone is insufficient. 1

Adults

• Azithromycin 1 g orally single dose (preferred) 1
• Alternative: Doxycycline 100 mg orally twice daily for 7 days 1
• Pregnant women: Erythromycin base or amoxicillin 500 mg orally three times daily for 7 days (avoid doxycycline, quinolones, tetracyclines) 1

Children

• Weight <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into four doses for 14 days 1
• Weight >45 kg but age <8 years: Azithromycin 1 g orally single dose 1
• Age ≥8 years: Azithromycin 1 g orally single dose OR doxycycline 100 mg orally twice daily for 7 days 1
• Neonates: Erythromycin base or ethylsuccinate 50 mg/kg/day divided into four doses for 14 days, OR azithromycin suspension 20 mg/kg/day once daily for 3 days 1

Important caveat: Monitor infants <6 weeks treated with erythromycin for infantile hypertrophic pyloric stenosis 1

Viral Conjunctivitis

Viral conjunctivitis is self-limited and requires only supportive care in most cases, with patient education on hygiene being the most critical intervention to prevent transmission. 1, 2

Adenoviral Conjunctivitis

• Supportive care: Cold compresses, preservative-free artificial tears 1
• Topical antibiotics are NOT indicated and should be avoided 1
• Patient education is paramount: Wash hands frequently, use separate towels and pillows, avoid close contact for 10-14 days from onset 1
• Follow-up in 1 week if corneal epithelial ulceration or membranous conjunctivitis present 1
• For corneal subepithelial infiltrates causing visual symptoms (occurring ≥1 week after onset): Consider low-dose topical corticosteroids (fluorometholone or loteprednol) with IOP monitoring, or cyclosporine 0.05-1% as steroid-sparing alternative 1

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical ganciclovir 0.15% gel 3-5 times daily (preferred due to less toxicity) OR trifluridine 1% solution 5-8 times daily 1
• Oral antivirals: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, OR famciclovir 250 mg twice daily 1
• Avoid topical corticosteroids as they potentiate HSV epithelial infections 1
• Neonates require immediate pediatric consultation for systemic HSV evaluation 1
• Follow-up within 1 week 1

Varicella Zoster Virus (VZV) Conjunctivitis

• Immunocompetent patients with persistent/recalcitrant disease: Acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, OR famciclovir 500 mg three times daily for 7 days 1
• Topical antibiotics may be used to prevent secondary bacterial infection of necrotic vesicles 1
• Immunocompromised patients require more aggressive treatment and infectious disease consultation 1

Molluscum Contagiosum

• Definitive treatment requires physical removal of eyelid lesions: Incision and curettage (with bleeding), simple excision, excision with cautery, or cryotherapy 1
• Conjunctivitis may take weeks to resolve after lesion removal 1
• Multiple/large lesions in adults suggest immunocompromised state—consider HIV testing 1

Allergic Conjunctivitis

Allergic conjunctivitis is treated with topical antihistamines and mast cell stabilizers, with itching being the key diagnostic feature. 2, 3

• First-line: Topical antihistamines (e.g., olopatadine, ketotifen) and/or mast cell stabilizers 2
• Avoid allergen exposure when possible 3
• Topical corticosteroids reserved for severe cases (vernal keratoconjunctivitis) with IOP monitoring 1
• Nonsteroidal anti-inflammatory agents may be considered 3

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Critical Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately for any of the following: 7

• Visual loss or decreased vision
• Moderate to severe pain beyond mild discomfort
• Corneal involvement (epithelial defects, infiltrates, ulceration)
• Severe purulent discharge suggesting gonococcal infection
• Conjunctival scarring or membrane formation
• Lack of response to appropriate therapy after 3-4 days
• Recurrent episodes despite treatment
• Immunocompromised state
• Neonatal conjunctivitis (ophthalmia neonatorum)

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Infection Control and Prevention

Hand hygiene and avoiding shared personal items are the most effective measures to prevent transmission of infectious conjunctivitis. 1, 4, 7

• Patients should wash hands frequently and avoid touching eyes 1, 4
• Use separate towels, pillows, and avoid close contact during contagious period (typically 10-14 days for viral) 1, 7
• Patients may return to work/school after 24-48 hours of antibiotic treatment if symptoms improving (bacterial) 7
• Tonometer disinfection: Use 1:10 dilute bleach (sodium hypochlorite) soak; 70% isopropyl alcohol is no longer recommended 1

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Common Pitfalls to Avoid

• Do not prescribe topical antibiotics for viral conjunctivitis—they provide no benefit and contribute to resistance 1
• Do not use topical corticosteroids in HSV conjunctivitis—they worsen epithelial disease 1
• Do not rely on topical therapy alone for gonococcal or chlamydial conjunctivitis—systemic treatment is mandatory 1, 7
• Do not use trifluridine for >2 weeks—it causes inevitable epithelial toxicity 1
• Do not ignore chronic/recalcitrant conjunctivitis—it may indicate underlying malignancy (sebaceous carcinoma, lymphoma, squamous cell carcinoma) or inflammatory conditions (mucous membrane pemphigoid) 1