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Bacterial Conjunctivitis Treatment & Management

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

Approach Considerations

Bacterial conjunctivitises generally last 1-2 weeks and are usually self-limiting. The mainstay of treatment for bacterial conjunctivitis is topical antibiotic therapy. Ideally, the antibiotic should be specific for the causative organism. Unfortunately, bacterial culturing, although recommended, is not always available, and Gram stain may take several days to yield results.

For mild and non–vision-threatening bacterial conjunctivitis, older-generation antibiotics should be used. Later-generation antibiotics should be reserved for more serious infections to minimize bacterial resistance.[21] For moderate to severe bacterial conjunctivitis, the latest-generation fluoroquinolones provides excellent gram-negative and some gram-positive bacterial coverage. Fortified antibiotics are also used in severe cases. Systemic antibiotics are indicated for N gonorrhoeae and chlamydial infections. Surgical intervention is required only when indicated for the treatment of causative conditions, such as hordeolum, nasolacrimal duct obstruction, or sinusitis.

Steroid use in combination with antibiotics is controversial, and results are mixed in terms of decreasing the corneal scarring.[22, 23] Unfortunately, steroids may slow the rate of healing, increase the risk of corneal melting, and increase the risk for elevated intraocular pressures.

Povidone-iodine solution 1.25% ophthalmic solution may be a safe and viable alternative to topical antibiotics for treating bacterial conjunctivitis,[8] especially in resource-poor countries, where antibiotics may be hard to come by and/or expensive.

Inpatient care for bacterial conjunctivitis would be provided only if hospitalization is indicated for other reasons or if antibiotic treatment is required every 15 minutes around the clock (severe cases). It is important to realize that, in the inpatient setting, the differential diagnosis must be carefully considered since the patients tend to be ill. Therefore, it is more common to see a red eye due to endogenous endophthalmitis or an infected corneal ulcer in this population.

Serious consideration should be given to admitting patients with hyperacute bacterial conjunctivitis if the entire cornea cannot be visualized, as there may be an early corneal ulceration, especially in Neisseria infections.[18] Topical antibiotic, proper hygiene, and isolation are considerations for these patients.

Be aware of drug alerts, such as the Fusarium keratitis outbreak related to ReNu with MoistureLoc (Bausch & Lomb) in 2006 and the Acanthamoeba keratitis outbreak in 2003-2006 related to Complete Moisture Plus (AMO).

Also of special concern is trachoma, a devastating disease. See Trachoma.

Instruct patients to return for follow-up if they do not recover completely in a timely manner, so that therapy can be reassessed. Consider culture and conjunctival scrapings for resistant cases.

Please see the following for more information:

See the following for more information:

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Topical Antibiotic Therapy

Practice patterns for prescribing topical antibiotics vary. Most practitioners prescribe a broad-spectrum agent on an empirical basis without culture for routine, mild cases of bacterial conjunctivitis. Always be aware of the differential diagnosis by taking thorough case histories and careful evaluation of the ocular surface. Instruct patients to seek follow-up care if the expected improvement does not occur or if vision becomes affected.

For mild and non–vision-threatening bacterial conjunctivitis, older-generation antibiotics should be used. Later-generation antibiotics and the latest fluoroquinolones should be reserved for more serious infections to minimize bacterial resistance.[21] The following are older topical antibiotics that can be as efficacious:

  • Trimethoprim with polymyxin B
  • Gentamicin
  • Tobramycin
  • Neomycin
  • Ciprofloxacin
  • Ofloxacin
  • Gatifloxacin
  • Erythromycin

For moderate and severe bacterial conjunctivitis, the latest fluoroquinolones are generally effective. Severe infections may also require patient hospitalization to ensure consistent administration of fortified aminoglycoside-cephalosporin combination therapy or topical fluoroquinolone monotherapy treatment every 15 minutes to hourly. Both are effective treatments, although fortified antibiotics must be prepared in compounding pharmacies and must remain refrigerated because of their shorter shelf life.

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Neonatal Chlamydial and Gonococcal Infection

Bacterial culture is the recommended method of diagnosing chlamydial and gonococcal infections in newborns.

Chlamydial infection of the newborn requires systemic treatment of the neonate, the mother, and at-risk contacts. The neonate may be treated with erythromycin orally in liquid form 50 mg/kg/d in 4 divided doses for 2 weeks. Some newborns also require a second dose. The mother and at-risk contacts may be treated with doxycycline 100 mg orally twice daily for 7 days.

N gonorrhoeae infection of the newborn also requires systemic treatment of the neonate, the mother, and at-risk contacts. The neonate may be treated with intravenous aqueous penicillin G 100 units/kg/d in 4 divided doses for 1 week. The mother and at-risk contacts may be treated with a single dose of intramuscular ceftriaxone 125 mg followed by oral doxycycline 100 mg twice daily for 7 days.

Prophylaxis against ophthalmia neonatorum is a major force in the worldwide effort to prevent blindness.[24] Common regimens are the instillation of 1% silver nitrate solution, 1% tetracycline ointment, or 0.5% erythromycin ointment. Povidone iodide is also gaining popularity in this role.[8]

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Prevention of Bacterial Conjunctivitis

Hygiene and avoidance of close contact accomplish deterrence of bacterial conjunctivitis with infected individuals. Patients and household members should be educated to pay attention to hygiene and the avoidance of close contact with the infected individual. It is customary to advise the infected individual to avoid sharing towels and linens.

A patient with bacterial conjunctivitis should wash hands often and avoid contaminating public swimming pools. Workers and students often are excused from work or school during the first several days of treatment to decrease the possibility of spread.

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Consultations

Consultations with an infectious disease specialist and/or a pediatrician may be indicated in suspected or proven chlamydial or N gonorrhoeae infections.

An experienced ophthalmic pathologist can be an excellent resource in determining the cause of a resistant conjunctivitis by interpreting conjunctival scrapings.

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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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