Bacterial Conjunctivitis

All common bacteria may cause acute conjunctivitis. Presently, S. pneumoniae, H. influenzae, S. aureus, and P. aeruginosa are the most common pathogens. The most frequent causes of hyperacute conjunctivitis are N. gonorrhoeae and N. meningitidis. Risk factors for bacterial conjunctivitis include contact lens wear, exposure to infectious persons, compromised immune systems, nasolacrimal duct obstruction, and sinusitis. In the presence of a severe purulent discharge, culture of the conjunctiva is mandatory (see Fig. 41-3). Subcon-junctival hemorrhage may occur with bacterial conjunctivitis and is especially common with H. influenzae conjunctivitis.

Treatment of conjunctivitis is with a topical antibiotic, such as erythromycin or bacitracin. Tobramycin ophthalmic ointment may be used for many gram-positive and gram-negative conjunctivitis cases. Ciprofloxacin and ofloxacin also provide effective broad coverage of most types of conjunctivitis. Gonococcal and Haemophilus conjunctivitis require systemic and topical therapy. If the conjunctivitis does not improve within 2 to 3 days or the worsening symptoms develop, the patient should be referred to an ophthalmologist.

Ciprofloxacin and ofloxacin provide effective broad coverage of most causative organisms. Newer fluoroquinolones such as gatifloxacin and moxifloxacin provide more potent coverage and better penetration for gram-positive organisms than earlier types of fluoroquinolones. Topical steroids or antibiotic-steroid combinations for conjunctivitis or other causes of red eye should not be used unless the patient is under the care of an ophthalmologist.

Topical corticosteroids have four potentially serious ocular side effects and are contraindicated for conjunctivitis, as follows:

1. Steroids can facilitate penetration of an undetected corneal herpetic infection to the deeper corneal layers and cause corneal perforation.

2. Prolonged local use of the corticosteroids (usually >2 weeks) can cause chronic open-angle glaucoma.

3. Prolonged use of topical corticosteroids can cause cataracts.

4. Topical corticosteroids are capable of potentiating the development of fungal corneal ulcers.

In general, topical steroids should be reserved for patients under the care of an ophthalmologist.


Cultures of the conjunctiva are indicated in all cases of suspected infectious neonatal conjunctivitis (AAO, 2003) (SOR: A).

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