Suzanne Albrecht, PharmD, MSLIS


US Pharmacist 

In This Article

Bacterial Conjunctivitis

Bacterial conjunctivitis often presents similarly to the viral form. The best way to distinguish between them is by the discharge. Bacterial infection causes a more mucopurulent discharge, and when the patient awakens in the morning, the eyes are often "glued" shut.[8,12,13] For neonates, prevention strategies include prophylactic use of erythromycin 0.5% or tetracycline 1%.[3]

There are three classifications of bacterial conjunctivitis: hyperacute, acute, and chronic.[12] Hyperacute infection is often caused by Neisseria gonorrhoeae in sexually active adults.[12] There are many pathogens that can cause an acute infection, whereas Chlamydia trachomatis most often causes the chronic condition.[13]

Gonococcal Conjunctivitis

Gonococcal conjunctivitis can occur in adults and neonates. Symptoms in neonates typically occur before those of chlamydial conjunctivitis (1–7 days after birth), but may be delayed if prophylactic antibiotics have been used.[3] Often associated with systemic disease, the condition progresses quickly to a severe purulent infection that may result in eye pain, corneal infection, scarring and/or perforation, septicemia with arthritis, and meningitis, and can lead to blindness.[3,11,12] Immediate referral to an ophthalmologist is warranted.[12] One or both eyes may be affected.[3]

Often, patients have systemic disease (sometimes without symptoms); therefore, systemic and topical antibiotics are indicated.[3,13]

Nongonococcal Conjunctivitis

Nongonococcal conjunctivitis, an acute infection, is the most common form of bacterial conjunctivitis seen in primary care. There are many natural defenses against conjunctival infection, but sometimes bacteria overcome them.[2] Staphylococcus aureus is a common pathogen in adults, whereas Streptococcus pneumoniae and Haemophilus influenzae are more common in children.[12]Moraxella lacunata may also cause infection.[1,2] In infants and children, bacterial otitis media, pharyngitis, or sinusitis may lead to bacterial conjunctivitis, which without treatment may progress to severe infection.[3] Direct contact with contaminated hands is the most common means of transmission.[12]

Infection is often mild and self-limited in adults, but may progress to complications in children. One or both eyes may be affected, with the most common symptoms being bulbar conjunctival injection and mucopurulent discharge. Rarely will mild infection progress to corneal infection and preseptal cellulitis (infection of the eyelid and periorbital tissues).[3] When symptoms persist beyond 4 weeks (often with frequent relapses), the condition is considered chronic and the patient must be referred to an ophthalmologist.[2,12] S aureus is often the causative agent.[2]

Treatment is empirical, with a topical broad-spectrum antibiotic for 5 to 7 days.[1,3] Table 2 lists topical antibiotics used for nongonococcal conjunctivitis.[9,12]

Chlamydial Conjunctivitis

Chlamydial conjunctivitis can affect adults and neonates.[3,11] The most common cause of infectious neonatal conjunctivitis, chlamydial conjunctivitis is transmitted from the mother's genital tract.[11] Half of infants are infected at other sites, such as the nasopharynx, genital tract, or lungs.[3] In neonates, symptoms appear 5 to 19 days after birth (or earlier, if the placenta ruptures). Untreated, the condition can persist for 3 to 12 months.[3]

One or both eyes may be affected. Neonatal symptoms include eyelid edema, bulbar conjunctival injection, discharge (purulent or mucopurulent), and lack of follicles. Adults exhibit bulbar conjunctival injection, mucopurulent discharge, corneal pannus (vascularization), punctate epithelial keratitis, preauricular lymphadenopathy, and bulbar conjunctival follicles.[3]

Since infection is usually systemic, treatment includes both systemic and topical antibiotics.[3,13] Erythromycin ophthalmic ointment, along with a single 1-g dose of azithromycin or doxycycline 100 mg twice daily for 14 days, is efficacious.[12]