Approach Considerations
Bacterial conjunctivitis generally last 1-2 weeks and is usually self-limiting. The mainstay of treatment for bacterial conjunctivitis is topical antibiotic therapy, with the intent of significantly reducing the duration of symptoms and likelihood of contagion. Ideally, the antibiotic should be specific for the causative organism. Unfortunately, bacterial culturing, although recommended, is not always available nor cost-effective for routine cases, 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 creation of bacterial resistance in the ocular surface flora. [25] For moderate to severe bacterial conjunctivitis, the latest-generation fluoroquinolones provide 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 corneal scarring. [26, 27] Unfortunately, steroids may slow the rate of healing, increase the risk of corneal melting, and increase the risk of elevated IOP.
Povidone-iodine solution 1.25% ophthalmic solution may be a safe and viable alternative to topical antibiotics for treating bacterial conjunctivitis, [10] especially in resource-poor countries, where antibiotics may be hard to come by and/or expensive.
Inpatient care for bacterial conjunctivitis is highly unusual and 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 diagnoses must be carefully considered through internal medicine consultation since these patients tend to be ill. Therefore, it is more common to see a red eye due to endogenous endophthalmitis, hyperacute gonorrheal conjunctivitis, orbital cellulitis, or a perforated 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 peripheral corneal ulceration threatening perforation, especially in Neisseria infections. [20] 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). [24]
Also of special concern is trachoma, a devastating disease common in third-world countries characterized by chronic infection during youth and potentially blinding corneal and conjunctival scarring in mid-life. Although acute hospitalization is uncommon for trachoma, hospital-based preventive lid surgeries are central to trachoma management paradigms. See Trachoma.
Instruct patients to return for follow-up in a timely manner or if they do not recover completely, so that therapy can be reassessed. Consider culture and conjunctival scrapings for resistant cases.
Please see the following for more information:
Topical Antibiotic Therapy
Practice patterns for prescribing topical antibiotics vary. For routine mild cases of bacterial conjunctivitis, most practitioners prescribe a broad-spectrum agent on an empirical basis without obtaining a culture. Always be aware of the differential diagnosis by taking thorough case histories and carefully evaluating 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 the risk of developing microbial resistance. [25] The following are older topical antibiotics that remain efficacious:
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Trimethoprim with polymyxin B
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Azithromycin
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Gentamicin
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Tobramycin
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Neomycin
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Ciprofloxacin
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Ofloxacin
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Gatifloxacin
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Erythromycin
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Bacitracin
For moderate and severe bacterial conjunctivitis, the latest fluoroquinolones, including moxifloxacin, besifloxacin, and levofloxacin, are generally effective. Rare severe infections may also require patient hospitalization to ensure consistent administration of fortified aminoglycoside-cephalosporin combination therapy, fortified topical vancomycin, or topical fluoroquinolone monotherapy treatment every 15 minutes to hourly. All are effective treatments, although fortified antibiotics must be prepared without preservatives in compounding pharmacies and must remain refrigerated because of their shorter shelf life.
Neonatal Chlamydial and Gonococcal Infection
Bacterial culture is the recommended method of diagnosing chlamydial and gonococcal infections in newborns. RNA probe technology and immunoassays developed for the obstetrical industry are also potentially useful.
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. These patients are also susceptible to chlamydial pneumonitis and otitis media. 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. Strict daily attention to the peripheral cornea, conjunctival scarring, and membrane formation allows timely surgical action: corneal cyanoacrylate glue for corneal melts and glass rod lysis of the conjunctival membranes destined to become symblepharons without intervention. Amniotic membrane therapy may also be beneficial in more extreme cases.
Prophylaxis against ophthalmia neonatorum is a major force in the worldwide effort to prevent blindness. [28] Common regimens are the instillation of 1% silver nitrate solution, 1% tetracycline ointment, or 0.5% erythromycin ointment. Relatively inexpensive povidone iodine is also gaining popularity in this role. [10]
Prevention of Bacterial Conjunctivitis
Hygiene and avoidance of close patient contact and fomites deter bacterial conjunctivitis with infected individuals. Patients and household members should be educated to pay attention to hygiene and the avoidance of close proximity with the infected individual. It is customary to advise the infected individual to avoid sharing napkins, towels, pillow cases, 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.
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.
