Treatment of bacterial conjunctivitis

• general measures - attention to personal hygiene to prevent spread of disease; irrigation of the conjunctival sac with saline to remove secretions
  
  
• antibiotics - use a broad spectrum antibiotic drop or ointment, e.g. chloramphenicol ointment applied twice daily for five days. If investigation for the aetiologic agent has been undertaken then specific treatment may be identified
  • in consideration of the evidence:
    • antibiotic treatment in culture positive bacterial conjunctivitis is beneficial (1)
    • empirical antibiotic treatment in suspected bacterial conjunctivitis is likely to be beneficial (1)
    • acute bacterial conjunctivitis is frequently a self-limiting condition, but the use of antibiotics is associated with significantly improved rates of clinical and microbiological remission (2)
      • topical antibiotics are of benefit in improving early (days 2 to 5) clinical remission (RR 1.24, 95% CI 1.05 to 1.45); NNT 7 (4 to 15)
      • early microbiological remission (RR 1.77, 95% CI 1.23 to 2.54); NNT 3 (2 to 6)
• topical fluoroquinolone antibiotics such as ciprofloxacin and ofloxacin are no more effective for superficial ocular infections than chloramphenicol, but are indicated when the patient is sensitive to the former and there is resistance or adverse reactions to the latter. They are also relatively expensive (3)
• fourth-generation ophthalmic fluoroquinolones (moxifloxacin and gatifloxacin) have better efficacy against gram-positive bacteria than ciprofloxacin or ofloxacin (4,5)
  • moxifloxacin and gatifloxacin penetrates better into ocular tissues than older fluoroquinolones
  • moxifloxacin and gatifloxacin used for the treatment of conjunctivitis complicated with keratitis
• azithromycin twice daily for 3 days, is effective in the management of purulent bacterial conjunctivitis, especially in children (6)

Notes:

• a meta-analysis concluded that '..acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics...' (7)
• chloramphenicol eye drops containing boron
  • following a review of the available toxicological data and a calculation of daily exposure to boron from a typical dosing regimen, it was concluded that the balance between the benefits and risks of chloramphenicol eye drops containing borax or boric acid remains positive for children aged 0 to 2 years
  • chloramphenicol eye drops can be safely administered to children aged 0 to 2 years where antibiotic eye drop treatment is indicated

Reference:

1. Clin Evidence Concise 2003;10:141.
2. Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001211
3. Drug and Therapeutic Bulletin (1994). Fluoroquinolones for the eye. 32, 10: 78-9.
4. Schlech BA, Alfonso E. Overview of the potency of moxifloxacin ophthalmic solution 0.5%. Surv Ophthalmol. 2005 Nov;50 Suppl 1:S7-15.
5. Koss MJ. The effectiveness of the new fluoroquinolones against the normal bacterial flora of the conjunctiva.Ophthalmologe. 2007 Jan;104(1):21-7.
6. Cochereau I et al. 3-day treatment with azithromycin 1.5% eye drops versus 7-day treatment with tobramycin 0.3% for purulent bacterial conjunctivitis: multicentre, randomised and controlled trial in adults and children. Br J Ophthalmol. 2007 Apr;91(4):465-9.
7. Jefferis Jet al. Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis. Br J Gen Pract. 2011 Sep;61(590):e542-8. doi: 10.3399/bjgp11X593811.
8. Drug Safety Update volume 14, issue 12: July 2021: 1.Chloramphenicol eye drops containing borax or boric acid buffers: use in children younger than 2 years