What is the recommended treatment for pediatric conjunctivitis (pink eye) in children?

Treatment of Pediatric Conjunctivitis (Pink Eye)

For bacterial conjunctivitis in children older than 12 months, use topical fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin, ciprofloxacin, or besifloxacin) 4 times daily for 5-7 days as first-line treatment. 1, 2

Determine the Etiology First

The treatment approach depends entirely on whether the conjunctivitis is bacterial, viral, or allergic, as each requires fundamentally different management 1.

Bacterial Conjunctivitis Features:

• Mucopurulent discharge with matted eyelids upon waking 1, 3
• Can be unilateral or bilateral 4, 5
• Papillary reaction (not follicular) 5
• May have concurrent otitis media in children 4, 5

Viral Conjunctivitis Features:

• Watery discharge 1, 3
• Follicular reaction on inferior tarsal conjunctiva 1, 5
• Preauricular lymphadenopathy 1, 5
• Often starts unilateral but becomes sequentially bilateral 5
• May have concurrent upper respiratory infection 5

Allergic Conjunctivitis Features:

• Bilateral itching as the predominant symptom 1, 5
• Watery discharge 5
• History of atopy, asthma, or eczema 5
• Seasonal or perennial pattern 5

Treatment Algorithm by Etiology

Bacterial Conjunctivitis

Mild to Moderate Cases:

• Topical fluoroquinolones are FDA-approved for children >12 months: moxifloxacin 0.5%, levofloxacin 0.5%, gatifloxacin 0.5%, ciprofloxacin 0.3%, or besifloxacin 0.6% 1, 2
• Dose: 4 times daily for 5-7 days 1, 2
• Alternative if fluoroquinolones unavailable: gentamicin, tetracycline, or ofloxacin 0.3% 1
• Clinical evidence: Topical antibiotics shorten symptom duration from 72% cure at 8-10 days (placebo) to 91% cure (antibiotic), with bacterial eradication in 79% vs 31% 6

Severe Cases (copious purulent discharge, pain, marked inflammation):

• Obtain conjunctival cultures and Gram staining before treatment 4, 1
• Consider MRSA if from nursing home or unresponsive to fluoroquinolones—may require compounded topical vancomycin 4, 1

Special Bacterial Pathogens Requiring Systemic Treatment:

Gonococcal Conjunctivitis:

• Neonates: Ceftriaxone 25-50 mg/kg IV or IM single dose (max 125 mg) 1, 2
• Children <18 years: Ceftriaxone 125 mg IM single dose PLUS azithromycin 1 g oral single dose for concurrent chlamydial coverage 1, 2
• Daily follow-up until resolution is mandatory 4, 1
• Consider sexual abuse in all pediatric cases 4, 1, 2

Chlamydial Conjunctivitis:

• Neonates: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses for 14 days 1, 2
• Children <45 kg: Erythromycin 50 mg/kg/day divided into 4 doses for 14 days 1
• Children ≥45 kg but <8 years: Azithromycin 1 g oral single dose 1
• Children ≥8 years: Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 1
• Systemic therapy is mandatory because >50% of infants have concurrent nasopharyngeal, genital, or lung infection 4, 1
• Consider sexual abuse in all pediatric cases 4, 1, 2

Viral Conjunctivitis

Standard Adenoviral Conjunctivitis:

• No antibiotics—they provide no benefit and cause unnecessary toxicity 1, 5
• Supportive care only: refrigerated preservative-free artificial tears 4 times daily 1
• Cold compresses for comfort 1
• Topical antihistamines for symptomatic relief of itching 1
• Strict hand hygiene with soap and water 1, 5
• Avoid close contact for 7-14 days from symptom onset 1

Severe Adenoviral Cases (marked chemosis, severe lid swelling, epithelial sloughing, or membranous conjunctivitis):

• Consider topical corticosteroids (fluorometholone, rimexolone, or loteprednol) with close ophthalmology monitoring 1, 5
• Monitor intraocular pressure and perform pupillary dilation periodically 1

Herpes Simplex Virus (HSV) Conjunctivitis:

• Topical ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily 1
• Add oral antivirals: acyclovir, valacyclovir, or famciclovir 1
• Never use topical corticosteroids in HSV without antiviral coverage—they potentiate viral replication and can cause corneal perforation 1, 5

Allergic Conjunctivitis

• First-line: Topical antihistamines with mast cell-stabilizing activity (olopatadine or ketotifen) 1, 5
• Adjunctive measures: cold compresses, refrigerated preservative-free artificial tears, sunglasses as allergen barrier 1
• Avoid eye rubbing 4
• If symptoms persist after first-line therapy: brief 1-2 week course of low side-effect profile topical corticosteroids with IOP monitoring 1

Red Flags Requiring Immediate Ophthalmology Referral

Refer urgently if any of the following are present 4, 1, 2, 5:

• 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
• History of HSV eye disease
• Immunocompromised state
• All neonatal conjunctivitis (birth to 28 days)—requires immediate evaluation due to risk of corneal perforation, septicemia, and meningitis 2

Follow-Up Recommendations

• Routine bacterial conjunctivitis: Return in 3-4 days if no improvement 4, 1, 2
• Gonococcal conjunctivitis: Daily visits until resolution 4, 1
• Chlamydial conjunctivitis: Re-evaluate after treatment completion due to 19% treatment failure rate 4
• Children with acute bacterial conjunctivitis: Consider referral for internal ear exam to evaluate for concurrent otitis media 4

Critical Pitfalls to Avoid

• Never use oral antibiotics for routine bacterial conjunctivitis—topical therapy achieves superior conjunctival concentrations, and oral antibiotics are reserved exclusively for gonococcal and chlamydial infections 1
• Never prescribe antibiotics for viral conjunctivitis—they cause unnecessary toxicity and promote resistance 1, 5
• Never use topical corticosteroids in HSV conjunctivitis without antiviral coverage—this potentiates infection and can cause corneal perforation 1, 5
• Never miss gonococcal or chlamydial conjunctivitis in children—always consider sexual abuse and obtain appropriate cultures 4, 1, 2
• Never use doxycycline in children <8 years—causes permanent tooth discoloration 1
• Never use prolonged topical trifluridine (>2 weeks)—causes epithelial toxicity 1

Infection Control Measures

• Strict hand hygiene with soap and water 1, 5
• Avoid sharing towels, pillows, or personal items 5
• Children can return to school 24 hours after starting antibiotic treatment for bacterial conjunctivitis once symptoms begin improving 2
• For viral conjunctivitis, minimize contact with others for 10-14 days from symptom onset 5