Infectious Conjunctivitis

Background

• Infectious conjunctivitis (inflammation of the conjunctiva due to viral or bacterial infection) is usually self-limiting, and rarely results in serious complications.
• Adenovirus is the most common cause, but bacteria (Haemophilus influenzae and Streptococcus pneumoniae) are also common causes in children.

Evaluation

• Suspect infectious conjunctivitis in patients with conjunctival injection (red eye), ocular discharge, and possibly abnormal ocular sensation (itching, burning, or foreign body sensation).
• Factors that suggest a higher likelihood of bacterial conjunctivitis include gluey or sticky eyes in the morning, mucopurulent discharge, age < 6 years, and absence of itching or burning sensation, though no single factor or pattern is definitive.
• Refer patient to an ophthalmologist promptly if there is moderate or severe pain, photophobia, visual loss, corneal involvement, or hyperpurulent discharge (gonococcal conjunctivitis).
• Obtain a conjunctival smear and cultures if there is suspected infectious neonatal conjunctivitis, chronic or recurrent conjunctivitis, or suspected gonococcal conjunctivitis at any age (Strong recommendation).
• Consider a conjunctival smear and cultures in other patients with recurrent or severe purulent conjunctivitis, or conjunctivitis not responding to medication (Weak recommendation).

Management

• For presumed viral (or known adenoviral) conjunctivitis:
  • Inform patients that the condition is highly contagious and provide advice to reduce the risk of spread to the other eye or other people (Strong recommendation).
  • Consider symptomatic treatments with artificial tears, topical antihistamines, or cold compresses (Weak recommendation).
• For acute bacterial conjunctivitis:
  • Consider topical ophthalmic antibiotics to improve the rate of early clinical remission (Weak recommendation), or delayed antibiotics to allow for spontaneous resolution but reduce repeat clinic visits.
  • Topical ophthalmic antibiotic options include:
    • ciprofloxacin
      • 0.3% ophthalmic ointment: apply 1/2 inch ribbon to conjunctival sac 3 times daily for 2 days, then apply 1/2 inch ribbon 2 times daily for next 5 days
      • 0.3% ophthalmic solution: 1-2 drops in conjunctival sac every 2 hours while awake for 2 days, then 1-2 drops every 4 hours while awake for next 5 days
    • ofloxacin 0.3% ophthalmic solution (Ocuflox): 1-2 drops in affected eyes every 2-4 hours on days 1-2, then 1-2 drops into affected eyes 4 times daily on days 3-7
    • erythromycin 0.5% ophthalmic ointment: apply 1 cm ribbon to infected structure up to 6 times daily depending on severity of infection
    • sulfacetamide 10% ophthalmic ointment: apply small amount (approximately 1/2 inch ribbon) in conjunctival sacs of affected eyes every 3-4 hours and at bedtime for 7-10 days
    • trimethoprim/polymyxin B ophthalmic solution: 1 drop in affected eyes every 3 hours (maximum of 6 doses/day) for 7-10 days
    • bacitracin/polymyxin B ophthalmic ointment: apply ointment every 3 or 4 hours for 7-10 days, depending on severity of infection (FDA DailyMed 2020 Apr 6)
  • If otitis-conjunctivitis syndrome suspected, amoxicillin or amoxicillin-clavulanate are first-line oral antibiotics; see Acute otitis media (AOM) in children topic.
• For herpes simplex virus (HSV) conjunctivitis, prescribe antiviral treatment (such as topical ophthalmic ganciclovir 0.15% gel 3-5 times daily or oral famciclovir 250 mg twice daily) (Strong recommendation).
• For gonococcal conjunctivitis:
  • Treat with systemic antibiotics (such as ceftriaxone 1 g intramuscularly as single dose in adults, or 25-50 mg/kg [maximum 125 mg/dose] IV or intramuscularly in infants) (Strong recommendation).
  • Consider daily follow-up until resolution (Weak recommendation).
  • See also Neonatal conjunctivitis topic.
• For chlamydial conjunctivitis:
  • Treat with systemic antibiotics (such as azithromycin 1 g orally in single dose for patients ≥ 8 years old or who weigh ≥ 45 kg [99 lbs], or a 14-day course of erythromycin in children who weigh < 45 kg [99 lbs]) (Strong recommendation)
  • Reevaluate patients following treatment (Strong recommendation).
  • See also Neonatal conjunctivitis topic.
• Refer patients to an ophthalmologist immediately if there is pain, decreased visual acuity, or within 7 days if the conjunctivitis is not responding to therapy or there are signs of more complicated disease (Strong recommendation).
• Exclusion from school or daycare participation is often determined by local policies.