What are the recommended medications with dosages and frequencies, and other management measures for viral and bacterial conjunctivitis?

Medications and Management for Viral and Bacterial Conjunctivitis

Bacterial Conjunctivitis

First-Line Topical Antibiotics

For uncomplicated bacterial conjunctivitis, prescribe topical moxifloxacin 0.5% three times daily for 5-7 days, which provides superior gram-positive coverage including activity against some MRSA strains. 1

Alternative topical fluoroquinolones include:

• Levofloxacin 0.5%: 1-2 drops four times daily for 5-7 days 1
• Gatifloxacin 0.3%: 1-2 drops four times daily for 5-7 days 1
• Ciprofloxacin 0.3%: 1-2 drops four times daily for 5-7 days 1
• Besifloxacin 0.6%: 1-2 drops three times daily for 5-7 days 1

If fluoroquinolones are unavailable:

• Gentamicin 0.3%: 1-2 drops four times daily for 5-7 days 1
• Ofloxacin 0.3%: 1-2 drops four times daily for 5-7 days 1
• Tetracycline ointment: Apply to lower conjunctival sac four times daily for 5-7 days 1

Severe Bacterial Conjunctivitis (Loading Dose Protocol)

For severe purulent discharge with marked inflammation:

• Moxifloxacin 0.5%: 1 drop every 5-15 minutes for the first hour, then hourly until improvement, then three times daily to complete 7 days 1
• Obtain conjunctival cultures and Gram staining before initiating treatment 1

Gonococcal Conjunctivitis (Requires Systemic Therapy)

Adults:

• Ceftriaxone 250 mg IM single dose PLUS azithromycin 1 g oral single dose 1
• Add topical antibiotics (any fluoroquinolone four times daily) 1
• Perform saline lavage for comfort 1
• Daily monitoring until complete resolution is mandatory 1

Neonates:

• Ceftriaxone 25-50 mg/kg IV or IM single dose (maximum 125 mg) 1
• Add topical antibiotics and saline lavage 1
• Admit for observation with daily ophthalmology follow-up 1

Chlamydial Conjunctivitis (Requires Systemic Therapy)

Adults:

• Azithromycin 1 g oral single dose OR doxycycline 100 mg oral twice daily for 7 days 1
• No topical antibiotics needed 1

Neonates:

• Erythromycin base or ethylsuccinate 50 mg/kg/day oral divided into 4 doses for 14 days 1
• Monitor for infantile hypertrophic pyloric stenosis in infants <6 weeks 1
• Re-evaluate after treatment completion (19% failure rate) 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

MRSA Conjunctivitis

If no response to fluoroquinolones within 48-72 hours:

• Compounded topical vancomycin (dosing per compounding pharmacy protocol) 1
• Obtain cultures before switching therapy 1

Alternative When Antibiotics Unavailable

• Povidone-iodine 1.25% ophthalmic solution: Apply as directed, may be as effective as topical antibiotics 1

---

Viral Conjunctivitis

Adenoviral Conjunctivitis (Most Common)

No antiviral treatment is effective for adenovirus; management is purely supportive. 1

Supportive care:

• Refrigerated preservative-free artificial tears: 4 times daily 1
• Cold compresses: Apply to closed eyelids for comfort 1
• Topical antihistamines (second-generation): For itching relief, dosing per product instructions 1

Avoid:

• Topical antibiotics (no benefit, risk toxicity and resistance) 1
• Topical corticosteroids in routine cases (prolong viral shedding) 1

Severe adenoviral conjunctivitis with complications:

Only when marked chemosis, severe lid swelling, epithelial sloughing, or membranous conjunctivitis is present:

• Fluorometholone 0.1%, rimexolone 1%, or loteprednol 0.5%: 1 drop four times daily, taper slowly once controlled 1
• Requires close monitoring for elevated intraocular pressure and cataract 1
• Measure IOP periodically and perform dilated exam 1

Herpes Simplex Virus (HSV) Conjunctivitis

Topical antiviral options:

• Ganciclovir 0.15% gel: 3-5 times daily until healed, then 3 times daily for 7 days 1, 2
• Trifluridine 1% solution: 5-8 times daily until healed, then 5 times daily for 7 days (maximum 2 weeks to avoid epithelial toxicity) 1, 2

Oral antiviral options (add to topical therapy):

• Acyclovir 400 mg oral five times daily for 7-10 days 1
• Valacyclovir 500 mg oral three times daily for 7-10 days 1
• Famciclovir 250 mg oral three times daily for 7-10 days 1

Critical contraindication:

• NEVER use topical corticosteroids in HSV conjunctivitis without antiviral coverage—they potentiate viral replication and worsen infection 1, 2

Herpes Zoster Ophthalmicus (VZV)

Systemic antiviral therapy (initiate within 72 hours of rash onset):

• Valacyclovir 1000 mg oral three times daily for 7-10 days (preferred) 3
• Acyclovir 800 mg oral five times daily for 7-10 days 3
• Famciclovir 500 mg oral three times daily for 7-10 days 3

Topical management:

• Apply topical antibiotics (any broad-spectrum) to vesicular lesions to prevent secondary bacterial infection 3
• Topical antivirals alone are ineffective for VZV conjunctivitis 3, 2

Corticosteroid use:

• Absolutely contraindicated during active epithelial viral infection 3
• May be used ONLY after epithelial healing for inflammatory complications (stromal keratitis, uveitis) under ophthalmologist supervision 3

Complicated cases:

• Intravenous acyclovir for severe or disseminated disease 3

---

General Management Measures (Both Bacterial and Viral)

Infection Control

• Strict handwashing with soap and water 1
• Avoid close contact for 7-14 days in viral conjunctivitis 1
• Discard multiple-dose eyedrop containers after infection resolves 1
• No contact lens wear until completely resolved 1

Follow-Up Strategy

• Return in 3-4 days if no improvement 1
• For gonococcal conjunctivitis: daily visits until resolution 1
• For chlamydial conjunctivitis: re-evaluate after treatment completion 1

Red Flags Requiring Immediate Ophthalmology Referral

• Visual loss or significant vision change 1
• Moderate to severe pain (beyond mild irritation) 1
• Severe purulent discharge suggesting gonococcal infection 1
• Corneal involvement (opacity, infiltrate, ulcer) 1
• Conjunctival scarring 1
• Lack of response to therapy after 3-4 days 1
• Recurrent episodes 1
• History of HSV eye disease 1
• Immunocompromised state 1
• Neonatal conjunctivitis (requires systemic treatment coordinated with pediatrician) 1

Special Populations

Contact lens wearers:

• Reserve fluoroquinolones (ofloxacin or ciprofloxacin) due to Pseudomonas risk 1
• Discontinue lens wear until completely resolved 1

Pregnant women:

• Avoid doxycycline and quinolones 1
• Use erythromycin or azithromycin for chlamydial coverage 1

Children with gonococcal or chlamydial conjunctivitis:

• Consider sexual abuse and document with standard culture 1
• Treat sexual partners 1

---

Critical Pitfalls to Avoid

• Do not use combination antibiotic-steroid drops (e.g., Tobradex) without definitively ruling out viral conjunctivitis, especially HSV and adenovirus 1
• Do not use topical corticosteroids in HSV without concurrent antiviral coverage 1, 2
• Do not use trifluridine for more than 2 weeks (causes epithelial toxicity) 1, 2
• Do not rely on topical antibiotics alone for gonococcal or chlamydial conjunctivitis—systemic therapy is mandatory 1
• Do not delay referral for gonococcal conjunctivitis—corneal perforation can occur within 24 hours 1
• Do not prescribe oral antibiotics for routine bacterial conjunctivitis when topical drops are unavailable—mild cases are self-limited 1