What is the treatment for conjunctivitis in an otherwise healthy individual?

Treatment of Conjunctivitis

Treatment depends entirely on the etiology: use topical fluoroquinolones for bacterial conjunctivitis, topical antihistamines with mast-cell stabilizing properties for allergic conjunctivitis, and supportive care only for viral conjunctivitis. 1

Bacterial Conjunctivitis

For mild to moderate bacterial conjunctivitis, prescribe a 5-7 day course of broad-spectrum topical antibiotic. 1

First-Line Antibiotic Options

• Topical fluoroquinolones (moxifloxacin 0.5%, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) are the preferred agents, providing coverage against Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. 1
• Moxifloxacin 0.5% three times daily offers superior gram-positive coverage, including activity against some MRSA strains, with 81% complete resolution at 48 hours. 1
• No single antibiotic has proven superiority over others, so choice can be based on dosing convenience, cost, and local resistance patterns. 1
• Alternative options include erythromycin ointment 2, bacitracin ointment 3, polymyxin B/trimethoprim drops, or ofloxacin 0.3% four times daily. 1

Important Clinical Context

• Mild bacterial conjunctivitis is self-limited in immunocompetent adults, with 64% resolving spontaneously by days 6-10 without treatment. 1
• Topical antibiotics provide earlier clinical and microbiological remission (68.2% cure rate vs 55.5% with placebo by days 4-9), allowing faster return to work or school. 1
• If no improvement occurs after 3-4 days of treatment, re-evaluate for resistant organisms or alternative diagnoses. 1, 4

Special Bacterial Pathogens Requiring Systemic Therapy

Gonococcal and chlamydial conjunctivitis require systemic antibiotics in addition to topical therapy—topical treatment alone fails. 1

Gonococcal Conjunctivitis (Adults)

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose. 1
• Requires daily monitoring until resolution—can cause corneal perforation if untreated. 1
• Obtain conjunctival cultures and Gram staining before initiating treatment. 1
• Hospitalization may be necessary for severe cases. 4

Chlamydial Conjunctivitis (Adults)

• Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days. 1
• Systemic therapy is mandatory because more than 50% of patients have concurrent infection at other sites. 1, 4
• Treat sexual partners concurrently and screen for other sexually transmitted infections. 1

Neonatal Bacterial Conjunctivitis

• Gonococcal: Ceftriaxone 25-50 mg/kg IV or IM single dose. 1
• Chlamydial: Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided into 4 doses for 14 days (monitor for infantile hypertrophic pyloric stenosis in infants <6 weeks). 1
• Requires immediate ophthalmology referral and systemic treatment coordinated with pediatrician. 1
• Consider sexual abuse in children with gonococcal or chlamydial conjunctivitis. 1

MRSA Considerations

• Consider MRSA in patients from nursing homes or with community-acquired infections. 1
• If unresponsive to fluoroquinolones within 48-72 hours, compounded topical vancomycin may be required, as MRSA isolates are generally resistant to fluoroquinolones but susceptible to vancomycin. 1

Viral Conjunctivitis

No proven effective treatment exists for adenoviral conjunctivitis—management is supportive care only. 1

Supportive Care Measures

• Refrigerated preservative-free artificial tears 4 times daily to dilute viral particles and inflammatory mediators. 1
• Cold compresses for symptomatic relief. 1
• Topical antihistamines (second-generation) for itching and discomfort. 1
• Avoid topical antibiotics—they provide no benefit and cause unnecessary toxicity and resistance. 1, 4

When to Consider Topical Corticosteroids

• Use only in severe adenoviral cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis. 1
• Requires close ophthalmology monitoring for elevated intraocular pressure and cataract formation. 1
• Corticosteroids can prolong adenoviral infections and should never be used without ophthalmology supervision. 1

Herpes Simplex Virus (HSV) Conjunctivitis

• Topical ganciclovir 0.15% gel 3-5 times daily OR topical trifluridine 1% solution 5-8 times daily. 1
• Add oral antivirals: acyclovir, valacyclovir, or famciclovir. 1
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage—they potentiate infection. 1
• Prolonged trifluridine use (>2 weeks) causes epithelial toxicity. 1

Infection Control

• Strict hand hygiene with soap and water is the single most important measure to prevent transmission. 1, 4
• Avoid close contact for 7-14 days from symptom onset. 1
• Discard multiple-dose eyedrop containers to avoid cross-contamination. 1

Allergic Conjunctivitis

Topical antihistamines with mast cell-stabilizing properties are first-line treatment. 1, 4

Treatment Algorithm

1. First-line: Second-generation topical antihistamine/mast-cell stabilizers (olopatadine, ketotifen). 1
2. Adjunctive measures: Cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier, avoid eye rubbing. 1, 4
3. Second-line (if symptoms persist): Brief 1-2 week course of low side-effect profile topical corticosteroids with monitoring of intraocular pressure. 1
4. Persistent/recurrent cases: Mast cell stabilizers for maintenance. 4

Important Precautions

• Avoid chronic use of topical vasoconstrictors—they cause rebound vasodilation. 1
• Oral antihistamines may worsen dry eye syndrome and exacerbate allergic conjunctivitis. 1

Giant Papillary Conjunctivitis

• Discontinue contact lens use in conjunction with topical anti-inflammatory agents. 1
• Measure intraocular pressure at baseline and periodically if corticosteroids are used. 1

Urgent Ophthalmology Referral Indications

Refer immediately if any of the following are present: 1, 4

• Visual loss or decreased vision
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement (infiltrate, ulcer, opacity)
• Conjunctival scarring
• Lack of response to therapy after 3-4 days
• Recurrent episodes
• History of HSV eye disease
• Immunocompromised state
• Neonatal conjunctivitis (requires systemic treatment)
• Suspected gonococcal conjunctivitis (can cause corneal perforation)

Critical Pitfalls to Avoid

• Failing to obtain cultures before treating suspected gonococcal conjunctivitis leads to poor outcomes including vision loss. 1
• Missing sexual abuse in children with gonococcal or chlamydial conjunctivitis has serious consequences. 1
• Using topical corticosteroids in HSV conjunctivitis without antiviral coverage potentiates infection. 1
• Indiscriminate antibiotic use for viral conjunctivitis contributes to resistance and causes unnecessary adverse effects. 1, 4
• Delayed referral for gonococcal conjunctivitis can lead to corneal perforation. 1