What is the recommended management for a pediatric patient with pseudomembrane conjunctivitis?

Management of Pseudomembranous Conjunctivitis in Pediatric Patients

The management of pseudomembranous conjunctivitis in children requires immediate identification of the underlying etiology, with treatment ranging from topical fluoroquinolones for bacterial causes to systemic plasminogen replacement for ligneous conjunctivitis, while severe cases with purulent discharge, visual loss, or corneal involvement mandate urgent ophthalmology referral. 1

Initial Assessment and Red Flags

When evaluating a pediatric patient with pseudomembranous conjunctivitis, immediately assess for the following features that require urgent ophthalmology referral: 1

• Visual loss or decreased vision
• Moderate to severe pain
• Severe purulent discharge
• Corneal involvement or infiltrates
• Conjunctival scarring

Hospitalization is mandatory for neonatal conjunctivitis and may be necessary for severe gonococcal conjunctivitis requiring parenteral therapy. 1

Etiologic Considerations and Specific Management

Bacterial Pseudomembranous Conjunctivitis

For bacterial causes in children older than 12 months without severe features: 2, 3, 4

• First-line treatment: Topical fluoroquinolone antibiotics (levofloxacin, moxifloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) applied 4 times daily for 5-7 days
• Alternative option: Polymyxin B/trimethoprim if fluoroquinolones are unavailable 2, 4
• Obtain conjunctival cultures before starting treatment if severe purulent discharge is present 2, 3

Topical antibiotics reduce symptom duration from 7 days (untreated) to 5 days and enhance bacterial eradication. 2, 5 However, be aware that methicillin-resistant S. aureus (MRSA) is increasingly common and may require compounded vancomycin based on culture results. 3, 4

Gonococcal Conjunctivitis

This requires systemic antibiotic therapy in addition to topical treatment: 2, 3, 4

• Ceftriaxone 125 mg IM single dose for children weighing <45 kg
• Ceftriaxone 250 mg IM for children weighing ≥45 kg
• Daily follow-up until resolution is mandatory
• Sexual abuse must be considered and reported to appropriate authorities 1, 2, 3

Chlamydial Conjunctivitis

Systemic therapy is required (topical therapy alone is insufficient): 1, 2, 3

• For children <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses for 14 days
• For children ≥8 years: Azithromycin 1 g orally single dose OR doxycycline
• More than 50% of infants with chlamydial conjunctivitis have infection at other sites (nasopharynx, genital tract, lungs), necessitating systemic treatment 1
• Sexual abuse must be considered in children with this condition 1, 2

Ligneous Conjunctivitis

This rare chronic childhood pseudomembranous conjunctivitis is caused by plasminogen deficiency: 1, 6

• Treatment options include:
  • Intravenous lys-plasminogen (most effective systemic replacement therapy)
  • Topical plasminogen drops
  • Surgical excision with immediate anticoagulation and immunosuppression
• Surgical excision alone often fails, but may be effective when combined with systemic therapy 1, 6
• This condition affects mucous membranes in the mouth, nasopharynx, trachea, and female genital tract 1

Herpes Simplex Virus Conjunctivitis

If HSV is suspected with pseudomembranous features: 1

• Topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily
• Oral antivirals: Acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily
• Avoid topical corticosteroids as they potentiate HSV epithelial infections 1
• Neonates require prompt pediatric consultation due to life-threatening systemic HSV infection 1

Follow-Up Protocol

Schedule re-evaluation in 3-4 days if no improvement is noted. 1, 2, 3, 4 This timeline is critical because:

• Lack of response suggests resistant organisms, alternative diagnosis, or need for culture 2, 3, 4
• Bacterial resistance is an increasing concern, particularly with MRSA 2, 3, 4

Infection Control and Return to School

Hand washing is crucial to reduce transmission risk. 1, 2, 3, 4 Children can generally return to school once treatment has been initiated for 24 hours and symptoms begin to improve. 2, 3, 4

Common Pitfalls to Avoid

• Do not use topical corticosteroids without ophthalmology consultation, as they worsen infectious causes and potentiate HSV infections 1, 4
• Do not miss gonococcal or chlamydial infection, which require systemic therapy and consideration of sexual abuse 1, 2, 3, 4
• Do not rely on topical therapy alone for chlamydial conjunctivitis, as systemic sites are often infected 1, 2
• Consider concurrent otitis media in children with bacterial conjunctivitis and refer for internal ear examination 1, 2, 7