Bacterial conjunctivitis

Background

Schematic diagram of anterior segment of human eye (horizontal section of the right eye). 1. Lens, 2. Zonule of Zinn or ciliary zonule, 3. Posterior chamber and 4. Anterior chamber with 5. Aqueous humour flow; 6. Pupil, 7. Corneosclera with 8. Cornea, 9. Trabecular meshwork and Schlemm's canal. 10. Corneal limbus and 11. Sclera; 12. Conjunctiva, 13. Uvea with 14. Iris, 15. Ciliary body.

• 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)