Treatment of Bacterial Conjunctivitis in Children
For children older than 12 months with mild to moderate bacterial conjunctivitis, treat with a topical broad-spectrum antibiotic (preferably a fluoroquinolone like moxifloxacin or levofloxacin) applied 4 times daily for 5-7 days. 1
Treatment Algorithm by Severity
Mild to Moderate Cases (Most Common)
- Apply topical broad-spectrum antibiotic 4 times daily for 5-7 days 2, 1
- FDA-approved fluoroquinolones for children ≥12 months include levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, and besifloxacin 1
- Alternative options include aminoglycosides (tobramycin), polymyxin B-trimethoprim, or polymyxin B-bacitracin 3, 4
- No single antibiotic has proven superiority over others for uncomplicated cases, so choose the most convenient or least expensive option 5, 2
The evidence strongly supports topical antibiotics: they achieve clinical cure in 62% of children by days 3-5 versus only 28% with placebo, and bacterial eradication occurs in 71% versus 19% 4. Treatment also reduces transmissibility and allows earlier return to school 2.
Severe Cases (Copious Purulent Discharge, Marked Pain/Inflammation)
- Obtain conjunctival cultures and Gram stain before starting treatment 5, 1
- Refer immediately to ophthalmology if any of the following are present: 1, 6
- Visual loss
- Moderate to severe pain
- Corneal involvement or infiltrates
- Severe purulent discharge
- No improvement after 3-4 days of treatment
Special Pathogen Considerations
Gonococcal Conjunctivitis (suspect if hyperacute onset, severe purulent discharge):
- Requires systemic ceftriaxone 125 mg IM PLUS topical antibiotics 1
- Daily follow-up until resolution 2, 1
- Mandatory evaluation for sexual abuse in children 1, 6
Chlamydial Conjunctivitis:
- Requires systemic antibiotic therapy (topical alone is insufficient) 2, 6
- Especially critical in infants who may have infection at other sites 2
- Consider sexual abuse evaluation 6
MRSA (increasing concern):
- Standard topical antibiotics may be ineffective 5, 1
- May require compounded vancomycin based on culture results 5, 1
Neonatal Conjunctivitis (Birth to 28 Days)
- Always requires immediate treatment and evaluation due to risk of corneal perforation, septicemia, and meningitis 1
- Gonococcal (manifests days 1-7): systemic ceftriaxone 125 mg IM plus topical antibiotics 1
Follow-Up Protocol
- Instruct parents to return in 3-4 days if no improvement 1, 6
- If no improvement after 3-4 days, consider resistant organisms or alternative diagnoses 1
- Treatment failure can occur in up to 19% of chlamydial cases 2
Return to School Guidelines
- Children can return to school 24 hours after starting treatment once symptoms begin improving 1
- Emphasize hand washing and avoiding sharing towels to reduce transmission 1
Common Pitfalls to Avoid
- Do not use topical corticosteroids unless under ophthalmology supervision, as they prolong bacterial shedding and worsen infection 6
- Do not assume all conjunctivitis is bacterial—viral conjunctivitis is self-limited and requires only supportive care 6
- The most common pathogens are Haemophilus influenzae (44.8%) and Streptococcus pneumoniae (30.6%), followed by Staphylococcus aureus 7
- Bacterial resistance is increasing, particularly with MRSA and pneumococcal strains 5, 1, 8