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Bacterial Conjunctivitis Medication

  • Author: Karen K Yeung, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Dec 04, 2015
 

Medication Summary

Most bacterial conjunctivitises are self-limiting,[10] although topical antibiotics are recommended[25] because they can shorten the duration of the disease[26] and prevent the spread of infection. Broad-spectrum antibiotics are generally used empirically as first-line therapy for bacterial conjunctivitis. Topical as opposed to oral antibiotics is recommended to deliver high levels of the drug directly to the site of infection, exceeding what is normally achieved in body tissues by oral or parenteral routes. Therefore, the antibiotic spectrum of the individual drug is enhanced.

For severe conjunctivitis marked by copious purulent discharge and eye inflammation, cultures are needed to guide the choice of antibiotic. Fortified antibiotics such as combination aminoglycosides and cephalosporins have a similar efficacy profile to fluoroquinolones. Resistance to early-generation fluoroquinolones, however, has been increasing. Oral antibiotics are recommended for gonococcal and chlamydial infections.

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Antibiotics

Class Summary

Most cases of routine bacterial conjunctivitis respond to the commercially available combination of antibiotics.

Although the aminoglycosides are used in other fields of medicine primarily to treat gram-negative bacteria, the spectrum of efficacy expands to include gram-positive bacteria when used topically for conjunctivitis. Aminoglycosides are not used orally and hence have lower rates of bacterial resistance. They are especially effective against gram-negative organisms. These are especially useful in mild bacterial conjunctivitis. Polymyxin B is also efficacious for mild conjunctivitis, especially in pediatric patients, but it may blur visions because it is in an ointment form.

Fluoroquinolones inhibit bacterial DNA gyrase and topoisomerase IV. They offer broad-spectrum coverage for bacterial conjunctivitis; however, owing to antibiotic overuse and misuse, bacterial resistance is increasing for this class of antibiotics, especially among older-generation fluoroquinolones. Fluoroquinolones have gained popularity in ocular therapy owing to their efficacy in the treatment of bacterial corneal ulcers, although many bacterial-resistant strains are emerging. Later-generation fluoroquinolones should be reserved for more severe cases of conjunctivitis. Older fluoroquinolones are effective for milder infections.

Regardless of the topical antibiotic regimen chosen, start off with a higher frequency of dosing (eg, q2h) for the first 1-2 days before decreasing the dosage (eg, qid) for the subsequent 5-7 days. Reiterate to the patient the importance of compliance with antibiotic drugs to ensure conjunctivitis resolution and especially to prevent bacterial resistance.

Neonatal chlamydial infection is treated with oral erythromycin. Doxycycline is used to treat the mother of a neonate with chlamydial infection as well as her at-risk contacts.

Intravenous penicillin G is used for neonatal gonorrhea infections. Third-generation cephalosporins are used in the treatment of adult gonorrhea infections.

Besifloxacin ophthalmic (Besivance)

 

Besifloxacin is a broad-spectrum fluoroquinolone antimicrobial ophthalmic suspension indicated for bacterial conjunctivitis approved for both children and adults to be used tid for 7 days. This agent is available as a 0.6% ophthalmic suspension. It has no systemic formulation, thereby lowering the rate of bacterial resistance. Susceptible bacteria include CDC coryneform group G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), H influenzae, Moraxella lacunata, S aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis, Streptococcus oralis, S pneumoniae, and Streptococcus salivarius

Gatifloxacin ophthalmic solution 0.3% (Zymaxid)

 

A fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis, gatifloxacin elicits a dual mechanism of action by possessing an 8-methoxy group, thereby inhibiting the enzymes DNA gyrase and topoisomerase IV. DNA gyrase is involved in bacterial DNA replication, transcription, and repair. Topoisomerase IV is essential in chromosomal DNA partitioning during bacterial cell division.

Gatifloxacin is indicated for bacterial conjunctivitis due to Corynebacterium propinquum, S aureus, S epidermidis, S mitis, S pneumoniae, or H influenzae. 

Moxifloxacin ophthalmic (Moxeza, Vigamox)

 

Moxifloxacin is a fourth-generation fluoroquinolone indicated for bacterial conjunctivitis due to H influenzae, S pneumoniae, and anaerobic bacteria. Compared to earlier-generation fluoroquinolones such as levofloxacin and ciprofloxacin, it is more effective against gram-positive bacteria and anaerobes. 

Levofloxacin ophthalmic

 

Levofloxacin is a third-generation fluoroquinolone and an S (-) enantiomer of ofloxacin. It inhibits DNA gyrase in susceptible organisms, thereby inhibiting relaxation of supercoiled DNA and promoting breakage of DNA strands. It has enhanced activity against S pneumoniae relative to earlier fluoroquinolone derivatives such as ciprofloxacin but is less effective than ciprofloxacin against gram-negative bacteria, especially Pseudomonas aeruginosa. It is also not as effective against MRSA. 

Ciprofloxacin ophthalmic (Ciloxan)

 

Ciprofloxacin is a second-generation fluoroquinolone that inhibits bacterial growth by inhibiting DNA gyrase. It is indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to this agent. It is effective in most cases of routine conjunctivitis, including those caused by S aureus, group A streptococci, H influenzae, and P aeruginosa. It may not cover all cases of S pneumoniae

Ofloxacin ophthalmic (Ocuflox)

 

Ofloxacin is a second-generation fluoroquinolone. A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect, ofloxacin inhibits bacterial growth by inhibiting DNA gyrase. It is indicated for superficial ocular infections of the conjunctiva or cornea caused by susceptible strains of microorganisms.

Tobramycin ophthalmic (Tobrex)

 

Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. It has a narrow spectrum but is effective against gram-negative organisms, especially P aeruginosa. It is available as a solution, ointment, and lotion and has been combined with steroids for combination antibiotic/steroid drops.

Gentamicin (Garamycin, Gentak)

 

Gentamicin is an aminoglycoside antibiotic used for gram-negative bacterial coverage, including Pseudomonas and gram-positive Staphylococcus. Gentamicin is commercially available in solution or ointment form. 

Trimethoprim/polymyxin B ophthalmic (Polytrim Ophthalmic Solution)

 

Polymyxin B is primarily used for resistant gram-negative organisms and is very ineffective against gram-positive organisms. Because it is particularly effective against S pneumoniae and H influenzae, which affect primarily children, it is the antibiotic of choice in pediatric patients. It is an ophthalmic drop to be used q4h for 7-10 days. 

Neomycin/polymyxin B/gramicidin ophthalmic (Neosporin Ophthalmic Solution)

 

Neomycin is used for treatment of minor infections; it inhibits bacterial protein synthesis and growth. Polymyxin B disrupts the bacterial cytoplasmic membrane, permitting leakage of intracellular constituents and causing inhibition of bacterial growth. Neosporin is available as an ophthalmic drop to be used q4h for 7-10 days.

Neomycin/polymyxin B/bacitracin ophthalmic (Neo-Polycin)

 

Neomycin is used in the treatment of minor infections. It inhibits bacterial protein synthesis and growth. It has excellent activity against gram-negative organisms and partial activity against gram-positive bacteria.

Azithromycin ophthalmic (AzaSite)

 

This second-generation ophthalmic macrolide antibiotic is indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, H influenzae, S aureus, S mitis group, and S pneumoniae. It is especially effective against pediatric conjunctivitises. Clinical trials demonstrate superior efficacy with azithromycin in comparison with tobramycin. Its highly viscous vehicle allows bid dosing the first 2 days and then qd for 5 more days. The decreased dosing allows for better patient compliance and hence quicker resolution of the conjunctivitis. 

Erythromycin Ophthalmic (Ilotycin)

 

Topical erythromycin is indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. It is effective in most cases of bacterial conjunctivitis, including those caused by S aureus, group A streptococci, S pneumoniae, and H influenzae. Because of the high level of bacterial resistance to this antibiotic, it has limited clinical use.

Bacitracin Ophthalmic

 

Bacitracin prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth. Most cases of routine bacterial conjunctivitis will respond to bacitracin, including those caused by group A streptococci, S aureus, S pneumoniae, and H influenzae. It is a highly effective against gram-positive pathogens. Because it is only available in an ointment form, the blurring of vision limits its use to primarily night-time use.

Azithromycin (Zithromax, Zmax)

 

A 1-g single dose or combination with ceftriaxone is an effective treatment for the drug of choice for adult inclusion (chlamydial) conjunctivitis. Azithromycin has broad but shallow antibacterial activity effective against some gram-positive bacteria, some gram-negative bacteria, and many atypical bacteria.

Doxycycline (Doryx, Vibramycin, Adoxa, Monodox)

 

Doxycycline inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline is a tetracycline antibiotic that is effective in the treatment of adult chlamydial infections. The dosage is 100 mg orally twice a day for 7 days.

Erythromycin base (Ery-Tab, PCE, E.E.S.)

 

Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is effective in the treatment of chlamydial infections. Erythromycin base 500 mg orally four times a day for 7 days or erythromycin ethylsuccinate 800 mg orally four times a day for 7 days are effective treatments for chlamydial infections.

Levofloxacin (Levaquin)

 

Levofloxacin inhibits bacterial topoisomerase IV and DNA gyrase, which are required for bacterial DNA replication and transcription. Administer 500 mg orally once daily for 7 days for chlamydial infection.

Ofloxacin

 

Used to treat complicated and uncomplicated skin and skin structure infections. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Agent acts by inhibition of DNA gyrase activity. Oral form has a reported bioavailability of 99%. Administer 300 mg orally twice daily for 7 days for chlamydial infections.

Ceftriaxone (Rocephin)

 

Ceftriaxone is a third-generation cephalosporin that arrests bacterial growth by binding to one or more penicillin-binding proteins. It has lower efficacy against gram-positive organisms but has excellent activity against susceptible pneumococcal organisms. It exerts an antimicrobial effect by interfering with the synthesis of peptidoglycan, a major structural component of the bacterial cell wall.

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Contributor Information and Disclosures
Author

Karen K Yeung, OD, FAAO Senior Optometrist, Arthur Ashe Student Health and Wellness Center, University of California, Los Angeles

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Coauthor(s)

Barry A Weissman, OD, PhD, FAAO Professor of Optometry, Southern California College of Optometry; Professor Emeritus of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Maria Elena De Shazer University of California at Los Angeles

Disclosure: Nothing to disclose.

Acknowledgements

Jerre Freeman, MD Founder, Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center College of Medicine

Jerre Freeman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

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