Bacterial conjunctivitis

Background

• Often due to staphylococcus or streptococcus

Clinical Features

• Painless, unilateral or bilateral mucopurulent discharge
  • Often causes adherence of the eyelids on awakening
• Chemosis is common

Differential Diagnosis

Conjunctivitis Types

• Viral conjunctivitis
  • Epidemic keratoconjunctivitis
  • Herpes zoster ophthalmicus
  • Herpes simplex keratitis
• Bacterial conjunctivitis
  • Gonorrheal conjunctivitis
  • Chlamydia conjunctivitis
• Allergic conjunctivitis
• Caustic keratoconjunctivitis

Evaluation

Workup

• Eye exam
• Fluorescein stain of cornea (especially in infants) to assess for corneal lesion
• Culture: if severe

Clinical diagnosis of conjunctivitis

Conjunctivitis

	Bacterial	Viral	Allergic
Bilateral	50%	25%	Mostly
Discharge	Mucopurulent	Clear, Watery	Cobblestoning, none
Redness	Yes	Yes	Yes
Pruritis	Rarely	Rarely	Yes
Additional	Treatment: Antibiotics	Treatment: Hygiene	Seasonal

Management

• Treatment for bacterial organisms is targeted toward S. aureus, S. pneumoniae, H. influenzae, Pseudomonas, N. gonorrhea, C. trachomatis
• Contact lens wearers should be given coverage for pseudomonas with one of the fluoroquinolone drops

Bacterial Conjunctivitis

• Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
• Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

• Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
• Erythromycin applied to the conjunctiva q6hrs for 7 days OR
• Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
• Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
• Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
• Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Chlamydial

• Doxycycline 100mg PO BID for 7 days OR
• Azithromycin 1g (20mg/kg) PO one time dose
• Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days
  • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

• Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
• Ceftriaxone 250mg IM one dose PLUS
• Azithromycin 1g PO one dose
• Newborn Treatment:
  • Prophylaxis: Erythromycin ophthalmic 0.5% x1
  • Disease manifests 1st 5 days post delivery (early onset)
  • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
  • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

Disposition

• Discharge with ophtho follow-up (if no improvement) in 3 - 4 days
• Bacterial conjunctivitis is highly contagious. Patients may return to work or school after 24 hours of topical therapy and a reduction in discharge from eye(s). Advise good hygiene practices.

See Also

• Conjunctivitis
• Eye Algorithm (Main)