eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Bacterial: Treatment & Medication

Author: David S Marlin, MD, Consulting Staff, Department of Ophthalmology, Kaiser Foundation Hospital, Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Jun 1, 2009

Treatment

Medical Care

• The mainstay of medical treatment of bacterial conjunctivitis is topical antibiotic therapy.
• Systemic antibiotics are indicated for N gonorrhoeae and chlamydial infections.
• Practice patterns for prescribing topical antibiotics vary. Most practitioners prescribe a broad-spectrum agent on an empirical basis without culture for a routine, mild-to-moderate case of bacterial conjunctivitis. Always be aware of the differential diagnosis, and instruct patients to seek follow-up care if the expected improvement does not occur or if vision becomes affected.
  • Sodium sulfacetamide, gentamicin, tobramycin, neomycin, trimethoprim and polymyxin B combination, ciprofloxacin, ofloxacin, gatifloxacin, and erythromycin are representatives of commonly used first-line agents.
  • Eye drops have the advantage of not interfering with vision. Ointments have the advantage of prolonged contact with the ocular surface and an accompanying soothing effect.
• 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/day in 4 divided doses for 2 weeks.
  • 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 per kg per day 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. Common regimens are the instillation of 1% silver nitrate solution, 1% tetracycline ointment, or 0.5% erythromycin ointment.

Surgical Care

• Surgical intervention is not required in the setting of bacterial conjunctivitis, except when indicated for the treatment of causative conditions, such as hordeolum, nasolacrimal duct obstruction, and sinusitis.

Consultations

• Consultations with infectious disease specialists and/or pediatricians 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.

Diet

• Dietary factors do not play a role in bacterial conjunctivitis, except in situations where a severe deficiency leads to an immunocompromised state.

Activity

• Activity precautions pertain to limiting the spread of the infection.
  • 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 during the first several days of treatment to decrease the possibility of spread.

Medication

Many antibiotic eye preparations can be used as first-line therapy in bacterial conjunctivitis. The justification for treating this condition empirically with a broad-spectrum topical agent is that relatively high levels of the drug are delivered directly to the site of infection. This level of drug concentration exceeds what is normally achieved in body tissues by oral or parenteral routes. Therefore, the antibiotic spectrum of the individual drug is enhanced.

This list of medicines is limited to a few common choices. Many other agents are available. Combination antibiotic-steroid medications are not discussed in this article, as these medicines play a role in postoperative care and only are used with extreme care in the setting of bacterial conjunctivitis.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. 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.

Fluoroquinolones have gained popularity in ocular therapy due to their efficacy in the treatment of bacterial corneal ulcers. Fluoroquinolones have been used mostly as second-line agents in routine bacterial conjunctivitis.

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.

Sodium sulfacetamide (Bleph-10, Cetamide, AK-Sulf)

Effective in most cases of bacterial conjunctivitis including those caused by Streptococcus pneumoniae, Haemophilus influenzae, and group A Streptococcus pyogenes. It may have some local activity against Chlamydia. Available as a solution and ointment preparation.

Gentamicin (Genoptic, Ocumycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Most cases of bacterial conjunctivitis will respond to this agent including pseudomonads, Staphylococcus aureus, group A streptococci, S pneumoniae, and H influenzae. Commercially available in solution or ointment form.

Erythromycin ointment (E-Mycin)

Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections. Effective in most cases of bacterial conjunctivitis including those caused by S aureus, group A streptococci, S pneumoniae, and H influenzae.

Azithromycin ophthalmic (AzaSite)

Ophthalmic macrolide antibiotic. Indicated for bacterial conjunctivitis caused by CDC coryneform group G bacteria, Haemophilus influenzae, Staphylococcus aureus, Streptococcus mitis group, and Streptococcus pneumoniae.

Bacitracin (AK-Tracin, Baciguent)

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.

Ciprofloxacin (Ciloxan)

Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ciprofloxacin. They are effective in most cases of routine conjunctivitis including those caused by S aureus, group A streptococci, H influenzae, and Pseudomonas aeruginosa. They may not cover all cases of S pneumoniae. Newer classes of fluoroquinolones (eg, gatifloxacin, moxifloxacin) are available and are sometimes used for conjunctivitis or a red eye, particularly in the perioperative period for eye surgery.

Trimethoprim and polymyxin B (Polytrim)

For ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic. Available as a solution and ointment. This combination of drugs is effective against the common causes of bacterial conjunctivitis including group A streptococci, S aureus, H influenzae, S pneumoniae, and pseudomonads.

Erythromycin (EES, Ery-Tab, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Effective in the treatment of chlamydial infections.

Doxycycline (Bio-Tab, Vibramycin, Doryx)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Doxycycline is a tetracycline class of antibiotic that is effective in the treatment of adult chlamydial infections.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Used in the hospital setting for neonatal gonorrheal infections.

Ceftriaxone (Rocephin)

Third-generation cephalosporin that is an adjunct in the treatment of adult gonorrhea infections. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Tobramycin (Tobrex)

Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Available as a solution, ointment, and lotion.

Neomycin (Mycifradin)

Used in the treatment of minor infections. Inhibits bacterial protein synthesis and growth.

Ofloxacin (Ocuflox)

Pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. Inhibits bacterial growth by inhibiting DNA gyrase. Indicated for superficial ocular infections of the conjunctiva or cornea caused by strains of microorganisms susceptible to ofloxacin.

Levofloxacin (Quixin)

S (-) enantiomer of ofloxacin. Inhibits DNA gyrase in susceptible organisms, thereby inhibiting relaxation of supercoiled DNA and promoting breakage of DNA strands.

Gatifloxacin ophthalmic solution 0.3% (Zymar)

Fourth-generation fluoroquinolone ophthalmic indicated for bacterial conjunctivitis. 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. Indicated for bacterial conjunctivitis due to Corynebacterium propinquum, S aureus, Staphylococcus epidermidis, Streptococcus mitis, S pneumoniae, or H influenzae.

Besifloxacin ophthalmic (Besivance)

Quinolone antimicrobial ophthalmic susp indicated for bacterial conjunctivitis. Susceptible bacteria include CDC coryneform group G (Corynebacterium pseudodiphtheriticum, Corynebacterium stratum), Haemophilus influenza, Moraxella lacunata, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Streptococcus mitis, Streptococcus oralis, Streptococcus pneumoniae, and Streptococcus salivarius. Available as a 0.6% ophthalmic suspension.

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