What is the recommended treatment for a patient with conjunctivitis?

Treatment for Conjunctivitis

Treatment of conjunctivitis must be tailored to the specific etiology: viral conjunctivitis requires only supportive care, mild bacterial conjunctivitis can be managed with observation or topical antibiotics, and allergic conjunctivitis responds to topical antihistamines with mast cell-stabilizing properties. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, immediately refer to ophthalmology if any of the following are present:

• Visual loss 1
• Moderate to severe pain (suggests keratitis, uveitis, or acute angle-closure glaucoma) 1, 3
• Severe purulent discharge (consider gonococcal infection) 1
• Corneal involvement on fluorescein staining 1
• Conjunctival scarring 1
• History of HSV eye disease 1
• Immunocompromised state 1
• Recurrent episodes 1

Viral Conjunctivitis

Viral conjunctivitis is the most common overall cause and requires supportive care only—antibiotics should be avoided. 1, 2, 4

Treatment Protocol:

• Refrigerated preservative-free artificial tears four times daily to dilute viral particles and inflammatory mediators 2
• Cold compresses for symptomatic relief 2, 5
• Topical antihistamines (second-generation) for itching and discomfort 2
• Strict hand hygiene with soap and water to prevent transmission 2
• Avoid close contact for 7-14 days from symptom onset 2

Special Considerations:

• Topical corticosteroids may be considered ONLY in severe adenoviral cases with marked chemosis, severe lid swelling, epithelial sloughing, or membranous conjunctivitis, but require close monitoring for elevated intraocular pressure and cataract 1, 2
• HSV conjunctivitis requires antiviral therapy: topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily, PLUS oral antivirals (acyclovir, valacyclovir, or famciclovir) 2
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage—they potentiate viral replication and worsen infection 2, 3

Bacterial Conjunctivitis

Mild Bacterial Conjunctivitis:

Mild bacterial conjunctivitis is often self-limited, resolving spontaneously in 64% of cases by days 6-10 without treatment. 1, 2 However, topical antibiotics provide earlier clinical remission (68.2% cure rate vs 55.5% with placebo by days 4-9) and allow faster return to work or school 2.

Recommended regimen: Topical moxifloxacin 0.5% three times daily for 5-7 days as first-line treatment, offering superior gram-positive coverage including some MRSA strains, with 81% complete resolution at 48 hours 2. Alternative options include topical fluoroquinolones (gatifloxacin, levofloxacin, ciprofloxacin, besifloxacin) or older agents (gentamicin, tetracycline, ofloxacin 0.3%) 1, 2, 6.

No single antibiotic has demonstrated superiority over others, so choice can be based on dosing convenience, cost, and local resistance patterns 1, 2.

Moderate to Severe Bacterial Conjunctivitis:

Characterized by copious purulent discharge, pain, and marked inflammation 1:

• Obtain conjunctival cultures and Gram staining before initiating treatment 1
• Consider MRSA, especially in nursing home residents or community-acquired infections 1
• Compounded topical vancomycin may be required for MRSA if unresponsive to fluoroquinolones within 48-72 hours 1, 2
• Advise return visit in 3-4 days if no improvement 1

Gonococcal Conjunctivitis:

Systemic antibiotic therapy is mandatory—topical therapy alone is insufficient. 1

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 2
• Saline lavage for comfort 1
• Daily follow-up until resolution 1, 3
• Treat sexual contacts concurrently 1
• Consider sexual abuse in children 1
• Rule out Neisseria meningitidis before concluding N. gonorrhoeae 1

Chlamydial Conjunctivitis:

Systemic therapy is mandatory because >50% of infants have concurrent infection at nasopharynx, genital tract, or lungs. 1

Adults: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2

Infants/Children <45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided into 4 doses for 14 days 1, 2

Children ≥45 kg but <8 years: Azithromycin 1 g oral single dose 2

Children ≥8 years: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 2

• Treat sexual contacts concurrently 1, 3
• Re-evaluate after treatment (treatment failure rate up to 19%) 1
• Consider sexual abuse in children 1
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used 1, 3

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are first-line treatment. 2, 3

Treatment Algorithm:

1. First-line: Second-generation topical antihistamine/mast cell stabilizers 2
2. Adjunctive measures: Cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier 1, 2, 3
3. Second-line (if symptoms persist): Brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure and for cataract 1, 2

Avoid chronic use of topical vasoconstrictors—they cause rebound vasodilation 2. Oral antihistamines may worsen dry eye syndrome and exacerbate allergic conjunctivitis 2.

Critical Pitfalls to Avoid

• Never use topical antibiotics indiscriminately—viral conjunctivitis will not respond, and antibiotics can induce toxicity and promote resistance 1, 3
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage 2, 3
• Avoid prolonged topical corticosteroid use (>2 weeks) without ophthalmology supervision—risk of steroid-induced glaucoma and cataract 2
• Do not use oral antibiotics for routine bacterial conjunctivitis—they are reserved exclusively for gonococcal and chlamydial conjunctivitis 2
• Always consider sexual abuse in children with gonococcal or chlamydial conjunctivitis 1, 2
• Delayed referral for gonococcal conjunctivitis can lead to corneal perforation and vision loss 2

Infection Control Measures

• Strict hand hygiene with soap and water is the single most important measure to prevent transmission 2, 3
• Infected individuals should use separate towels and avoid close contact during contagion period 1
• Disinfect surfaces with EPA-registered hospital disinfectant or 1:10 dilution of household bleach 1, 3
• Disinfect tonometers with dilute bleach soak (sodium hypochlorite) at 1:10 concentration 1
• Do NOT use 70% isopropyl alcohol, 3% hydrogen peroxide, or ethyl alcohol for tonometer disinfection 1

Follow-Up Recommendations

• Routine bacterial conjunctivitis: Return if no improvement in 3-4 days 1, 2
• Gonococcal conjunctivitis: Daily visits until resolution with interval history, visual acuity, and slit-lamp biomicroscopy at each visit 1
• Chlamydial conjunctivitis: Re-evaluate after treatment completion 1
• If corticosteroids prescribed: Baseline and periodic IOP measurement and pupillary dilation to evaluate for glaucoma and cataract 1, 2