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

Treatment of Conjunctivitis in Pregnancy

For pregnant patients with conjunctivitis, avoid doxycycline, quinolones, and tetracyclines; use erythromycin or azithromycin for chlamydial infection and amoxicillin as an alternative, with topical antibiotics safe for bacterial conjunctivitis and supportive care for viral cases. 1

Critical Medication Restrictions in Pregnancy

The most important consideration is avoiding teratogenic antibiotics:

• Never use: Doxycycline, quinolones (including fluoroquinolones like moxifloxacin, levofloxacin, ciprofloxacin), or tetracyclines 1
• These restrictions apply to both systemic and topical formulations when treating sexually transmitted conjunctivitis

Treatment by Etiology

Bacterial Conjunctivitis (Non-STI)

Topical broad-spectrum antibiotics are safe and effective for uncomplicated bacterial conjunctivitis in pregnancy:

• Use topical erythromycin, polymyxin B/trimethoprim, or azithromycin ophthalmic solution for 5-7 days 2, 3
• Topical fluoroquinolones should be avoided due to systemic absorption concerns, even though the risk is theoretical 1
• Clean eyelids with warm water before medication application 3

Chlamydial Conjunctivitis

Systemic therapy is mandatory because topical treatment alone fails for intracellular chlamydial infection 2:

• First-line: Azithromycin 1 g orally as a single dose 1
• Alternative: Amoxicillin 500 mg orally three times daily for 7 days 1
• Also acceptable: Erythromycin base (dose varies by formulation) 1
• Screen and treat sexual partners concurrently 2

Gonococcal Conjunctivitis

This is an ophthalmologic emergency requiring immediate referral and systemic antibiotics:

• Ceftriaxone 250 mg IM as a single dose 1
• Plus azithromycin 1 g orally as a single dose for concurrent chlamydial coverage 1
• Daily monitoring until resolution is essential to prevent corneal perforation 2
• Obtain conjunctival cultures and Gram staining before initiating treatment 2

Viral Conjunctivitis

Supportive care only, as no antiviral treatment is proven effective for adenoviral conjunctivitis 2, 3:

• Refrigerated preservative-free artificial tears 4 times daily 2, 3
• Cold compresses for symptomatic relief 2, 3
• Topical antihistamines (second-generation) for itching if needed 2
• Avoid topical antibiotics to prevent unnecessary adverse effects and resistance 2, 4

For HSV conjunctivitis (rare but serious):

• Topical ganciclovir 0.15% gel or trifluridine 1% solution 2
• Oral antivirals (acyclovir, valacyclovir) are pregnancy category B and can be used 2
• Never use topical corticosteroids without antiviral coverage as they potentiate HSV infection 2, 3

Allergic Conjunctivitis

Topical antihistamine/mast cell stabilizer combinations are safe:

• Second-generation topical antihistamines with mast cell stabilizing properties as first-line 2, 3
• Cold compresses and refrigerated artificial tears for additional relief 2, 3
• Allergen avoidance strategies (sunglasses, hypoallergenic bedding) 3
• If severe and unresponsive, a brief 1-2 week course of low-potency topical corticosteroids with IOP monitoring 2, 3

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present 2, 3:

• Visual loss or decreased vision
• Moderate to severe pain (not just irritation)
• Severe purulent discharge suggesting gonococcal infection
• Corneal involvement (infiltrate, ulcer, opacity, or fluorescein uptake)
• Conjunctival scarring or membrane formation
• Lack of response to appropriate therapy after 3-4 days
• History of HSV eye disease
• Immunocompromised state

Infection Control Measures

Strict hand hygiene is critical to prevent transmission, especially for viral conjunctivitis 2, 3:

• Wash hands with soap and water frequently (not just hand sanitizer) 2
• Avoid sharing towels, pillows, or personal items 5, 3
• Avoid close contact for 7-14 days from symptom onset in viral cases 2
• Return to work/activities after 24-48 hours of antibiotic treatment for bacterial conjunctivitis 5, 3

Common Pitfalls to Avoid

• Do not empirically prescribe fluoroquinolones in pregnancy without considering safer alternatives 1
• Do not miss gonococcal or chlamydial conjunctivitis, which require systemic antibiotics and can cause serious complications if treated with topical therapy alone 2
• Do not use corticosteroids indiscriminately, as they prolong adenoviral infections and worsen HSV infections 2, 3
• Do not forget to treat sexual partners in cases of STI-related conjunctivitis 2
• Do not delay referral for suspected gonococcal conjunctivitis, as corneal perforation can occur rapidly 2