Bacterial Conjunctivitis

1. Epidemiology
   1. Transmission
      1. Infectious for first 48 hours of treatment
2. Causes
   1. Newborns
      1. Chlamydial Conjunctivitis
      2. Gonorrheal Conjunctivitis
      3. See HSV Conjunctivitis in Viral Conjunctivitis
   2. Children
      1. Streptococcus Pneumoniae (*)
      2. HaemophilusInfluenzae (*)
      3. Staphylococcus species
      4. Moraxella species
   3. Adults
      1. Staphylococcus aureus (*)
      2. Staphylococcus epidermidis
      3. Streptococcus species
      4. Escherichia coli
      5. Pseudomonas species
      6. Moraxella species
      7. Chlamydial Conjunctivitis
      8. Gonorrheal Conjunctivitis (NeisseriaGonorrhea)
3. Symptoms
   1. Sudden onset
      1. Unilateral
      2. Progresses to other eye in 2-5 days
   2. Mucopurulent discharge
      1. Copious gray, yellow, or green discharge
      2. Consider Gonococcal Conjunctivitis (excessive pus)
   3. Matting of lashes in morning
   4. Significant irritation with stinging sensation or foreign body sensation
   5. Eyelid may appear puffy
4. Signs
   1. Variable Conjunctival injection
      1. Palpebral Conjunctiva is more affected than bulbar
   2. Lid edema
   3. No preauricular adenopathy
   4. No Corneal involvement
   5. Eyelid edema
   6. Intact Visual Acuity
5. Diagnosis
   1. Predictors of bacterial infection
      1. Copious Eye Discharge
      2. Eyes glued shut in morning
         1. Especially if both eyes glued shut (odds ratio: 15)
   2. Predictors of viral infection
      1. Itching eyes (if moderate to severe, likely Allergic Conjunctivitis)
      2. Prior episodes of Conjunctivitis
   3. Efficacy
      1. Eyes itch and not glued shut: 4% bacterial
      2. Glued shut, no itch, no prior history: 77% bacterial
   4. References
      1. Rietveld (2004) BMJ 329:206-10
6. Complications
   1. Blepharitis ("Granulated Eyelids")
      1. Seen in chronic Bacterial Conjunctivitis
      2. Colonization of lid margins by Staphylococcus aureus
   2. External Hordeolum (stye)
7. Course: Self-Limited
   1. Resolves in 2 weeks without treatment (65% improve within 2-5 days)
   2. Clears in 48-72 hours with treatment
   3. Serious complications are rare
8. Lab: Eye Culture Indications
   1. Severe cases
   2. Immune compromised state
   3. Contact lens use
   4. Newborns
   5. Failed initial treatment
9. Management
   1. Conditions requiring urgent ophthalmology referral
      1. Gonococcal Conjunctivitis
      2. Chronic or recurrent Conjunctivitis
      3. Conjunctivitis not improving after 7 days of treatment
   2. Protocol
      1. Consider observing without antibiotic therapy if no risk factors and have good follow-up
      2. Factors suggesting starting immediate antibiotics
         1. Healthcare workers (can not return to work until discharge ceases)
         2. Patients residing in health care facility or hospital
         3. Children attending daycare or school who cannot return until treatment started
         4. Immune compromised patient
         5. Uncontrolled Diabetes Mellitus
         6. Contact lens use
         7. Dry Eyes
         8. Recent ophthalmic surgery
   3. Preparations
      1. See Topical Eye Antibiotic
      2. Course
         1. Typically 7 days has been used
         2. Short duration of 3-5 days is probably sufficient
      3. General Approach with First Line Agents
         1. Daytime Agents
            1. Trimethoprim-Polymyxin B (Polytrim) solution 2 drops four times daily
            2. Avoid Sulfacetamide (low efficacy)
            3. Avoid Neomycin (Allergic Reaction is common)
         2. Nighttime agent (consider as soothing overnight management)
            1. Erythromycin 0.5% ointment nightly
      4. Broad Spectrum antibiotics for serious or refractory Bacterial Conjunctivitis
         1. Gentamicin (Gentak) 0.3% ointment or solution
         2. Tobramycin (Tobrex) 0.3% solution (ointment is not generic and is expensive)
         3. Ciprofloxacin (Ciloxan) 0.3% ointment or solution
         4. Ofloxacin (Ocuflox) 0.3% solution
      5. Direct treatment if specific bacterial eye infection suspected
         1. Chlamydia Conjunctivitis
         2. Gonorrhea Conjunctivitis
10. Resources (Include Patient Education)
    1. See Conjunctivitis Resources
11. References
    1. Cronau (2010) Am Fam Physician 81(2): 137-44
    2. Hovding (2008) Acta Ophthalmol 86(1): 5-17
    3. Sheikh (2005) Br J Gen Pract 55(521): 962-4
    4. Wikstrom (2008) Acta Ophthalmol 86(1): 2-4