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

Treatment of Bacterial Conjunctivitis

For mild bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily, choosing the most convenient or least expensive option since no evidence shows superiority of any particular agent. 1, 2

Initial Treatment Approach

Mild Cases

• Apply broad-spectrum topical antibiotic 4 times daily for 5-7 days 3, 1, 2
• Select the most convenient or least expensive option—clinical evidence does not demonstrate superiority of any particular antibiotic for uncomplicated cases 1, 2
• Effective first-line options include:
  • Aminoglycosides (tobramycin, gentamicin) 3, 1
  • Polymyxin B/trimethoprim 1
  • Bacitracin (applied 1-3 times daily) 4
  • Erythromycin (up to 6 times daily depending on severity) 5

Moderate to Severe Cases

• Reserve fluoroquinolones (moxifloxacin, gatifloxacin, ofloxacin, ciprofloxacin) for cases with copious purulent discharge, pain, and marked inflammation 1, 2
• Obtain conjunctival cultures and Gram staining before initiating treatment 3, 1, 2
• Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) provide better gram-positive coverage, including some MRSA strains 1

Contact Lens Wearers

• Use fluoroquinolones specifically due to higher risk of Pseudomonas infection 1

Special Populations Requiring Systemic Therapy

Gonococcal Conjunctivitis

• Requires systemic antibiotic therapy—topical treatment alone is insufficient 3, 1, 2
• Add saline lavage for comfort and faster resolution 1
• Daily follow-up until resolution is mandatory 2

Chlamydial Conjunctivitis

• Requires systemic antibiotic therapy, especially in infants who may have infection at other sites 3, 1, 2
• For neonates: erythromycin base or ethylsuccinate 50 mg/kg/day divided into 4 doses for 14 days 1
• No evidence supports adding topical therapy beyond systemic treatment 1
• Treatment failure occurs in up to 19% of cases, requiring follow-up evaluation 2

MRSA Infections

• May require compounded topical vancomycin since MRSA is resistant to most commercially available topical antibiotics including aminoglycosides and fluoroquinolones 1

Alternative When Antibiotic Access is Limited

• Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics and can be considered when access is limited 3, 1, 2

Follow-Up Protocol

• Instruct patients to return if no improvement after 3-4 days of treatment 3, 1, 2
• At follow-up, perform interval history, visual acuity measurement, and slit-lamp biomicroscopy 3, 1

Critical Pitfalls to Avoid

Do Not Use Topical Corticosteroids

• Avoid topical corticosteroids unless under close ophthalmologic supervision—they may prolong bacterial shedding and worsen infection 3
• Exception: brief course may be indicated for severe inflammation with baseline and periodic intraocular pressure monitoring 1

Do Not Prescribe Antibiotics for Viral Conjunctivitis

• Avoid antibiotics for viral conjunctivitis—this creates unnecessary costs and promotes resistance 1

Consider Sexual Abuse

• In children with gonococcal or chlamydial conjunctivitis, consider the possibility of sexual abuse 3, 1, 2

When to Refer to Ophthalmology

Immediate referral is indicated for: 3, 1

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Conjunctival scarring
• Lack of response to therapy
• Recurrent episodes
• Neonatal conjunctivitis (mandatory hospitalization) 1

Infection Control Measures

• Counsel patients on frequent hand washing and avoiding sharing personal items to prevent spread 3, 1
• Topical antibiotics reduce transmissibility and allow earlier return to school/work 1, 2