Treatment of Bacterial Conjunctivitis
For uncomplicated bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic applied 4 times daily, with the most convenient or least expensive option being appropriate for mild cases. 1
Initial Treatment Selection
Mild Bacterial Conjunctivitis
- Choose the most convenient or least expensive broad-spectrum topical antibiotic for 5-7 days, as no clinical evidence suggests superiority of any particular agent in mild cases. 1
- Acceptable first-line options include:
- Apply 4 times daily for the full treatment course 2
- Topical antibiotics accelerate clinical and microbiological remission by days 2-5, reduce transmissibility, and allow earlier return to school/work 1
Moderate to Severe Bacterial Conjunctivitis
- Reserve fluoroquinolones (moxifloxacin, gatifloxacin, ofloxacin, ciprofloxacin) for cases with copious purulent discharge, pain, and marked inflammation. 1
- Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) provide superior gram-positive coverage, including some methicillin-resistant S. aureus strains 1
- Obtain conjunctival cultures and Gram staining before initiating treatment if gonococcal infection is suspected. 1
Contact Lens Wearers
- Prescribe fluoroquinolones for contact lens wearers due to higher risk of Pseudomonas infection. 1
Special Clinical Scenarios Requiring Different Management
Gonococcal Conjunctivitis
- Requires systemic antibiotic therapy: ceftriaxone 1 g IM single dose plus azithromycin 1 g orally single dose for adults. 1
- Add saline lavage to promote comfort and faster resolution of inflammation 1
- Topical antibiotics alone are insufficient 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. 1
- For neonates: erythromycin base or ethylsuccinate 50 mg/kg/day divided into four doses daily for 14 days 1
- No evidence supports additional topical therapy beyond systemic treatment 1
- Treatment failure can occur in up to 19% of cases, requiring follow-up evaluation 2
MRSA Conjunctivitis
- May require compounded topical vancomycin, as MRSA organisms are resistant to fluoroquinolones and aminoglycosides. 1
- Standard commercially available topical antibiotics are generally ineffective 1
Follow-Up and Red Flags
When to Schedule Follow-Up
- Advise patients to return if no improvement after 3-4 days of treatment. 1, 3
- At follow-up, perform interval history, visual acuity measurement, and slit-lamp biomicroscopy 1
Immediate Ophthalmology Referral Required For:
- Visual loss 1
- Moderate to severe pain 1
- Severe purulent discharge 1
- Corneal involvement 1
- Conjunctival scarring 1
- Lack of response to therapy after 3-4 days 1
- Recurrent episodes 1
- Immunocompromised state or history of HSV eye disease 1
Infection Control Measures
Counsel patients on strict hand hygiene, avoiding eye rubbing, using separate towels, and avoiding close contact during the contagious period. 1
- Frequent hand washing is essential 1, 3
- Avoid sharing towels, pillowcases, and makeup 3
- Do not touch eyes 3
Important Pitfalls to Avoid
- Do not prescribe antibiotics for viral conjunctivitis, which promotes unnecessary costs and antibiotic resistance. 1
- Do not use topical corticosteroids routinely, as they may prolong bacterial shedding and worsen infection. 3
- Do not use antihistamines for bacterial conjunctivitis, as burning and itching are inflammatory symptoms from bacterial infection, not histamine-mediated allergic responses. 1
- Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1
- Bacterial resistance is a growing concern, particularly with MRSA infections 1
Alternative Treatment Option
Povidone-iodine 1.25% ophthalmic solution may be as effective as topical antibiotics and can be considered when access to antibiotics is limited. 1