BacterialConjunctivitis

Overview

Presentation

DDx

Workup

Treatment

Medication

Updated:Mar27,2014

PracticeEssentials

Background

Pathophysiology

Etiology

Epidemiology

Prognosis

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References

PracticeEssentials
Commoncausesofbacterialconjunctivitis,aninflammationofthebulbarand/orpalpebral
conjunctivas,includestaphylococci,streptococci,gonococci,andChlamydia.Complicationsare
expectedtodeveloponlyincasescausedbyextremelypathogenicbacteria,suchasCtrachomatisor
Neisseriagonorrhoeae.

Signsandsymptoms
Signsandsymptomsofbacterialconjunctivitisincludethefollowing:

Folliclesorpapillaeontheinflamedconjunctiva

Discharge:Morepurulentthaninviralconjunctivitis,withmorematteringoftheeyelid
marginsandgreaterassociateddifficultypryingtheeyelidsopenfollowingsleep

Enlargedpreauricularlymphnode:Unusualinbacterialconjunctivitisbutfoundinsevere
conjunctivitiscausedbyNgonorrhoeae

Eyelidedema:Oftenpresentinbacterialconjunctivitis,butmildinmostcases;severeeyelid
edemainthepresenceofcopiouspurulentdischargeraisesthesuspicionofNgonorrhoeae
infection

SeeClinicalPresentationformoredetail.

Diagnosis
Theuseofconjunctivalscrapingsinthediagnosisofbacterialconjunctivitiscanproceedasfollows:

Conjunctivalscrapingscanbeperformedwithtopicalanestheticandgentleuseofaplatinum
spatulaorsimilarbluntmetallicobject

Gramstainisusefulforidentifyingbacterialcharacteristics

GiemsastainishelpfulinscreeningforintracellularinclusionbodiesofChlamydia

Culturescanbecompletedforchlamydialandotherbacterialorganisms,aswellasforviralagents.
Fungalculturewouldbeunusualexceptinthesettingofacornealulcerorinthecaseofknown
contaminationofacontactlenssolution.Thecellularresponseinconjunctivitisdiffersaccordingtothe
cause,asfollows:

Bacterialinfections:Neutrophilspredominate

Viralinfections:Lymphocytespredominate

Allergicreactions:Eosinophilspredominate

SeeWorkupformoredetail.

Management
Themainstayoftreatmentforbacterialconjunctivitisistopicalantibiotictherapy,althoughsystemic
antibioticsareindicatedforNgonorrhoeaeandchlamydialinfections.Firstlineantibiotics
(administeredaseyedropsorointments)commonlyusedtotreatbacterialconjunctivitisincludethe
following:

TrimethoprimwithpolymixinB

Gentamicin

Tobramycin

Neomycin

Ciprofloxacin

Ofloxacin

Gatifloxacin

Erythromycin

Povidoneiodinesolution1.25%ophthalmicsolutionmaybeasafeandviablealternativetotopical
antibioticsfortreatingbacterialconjunctivitis,[1]especiallyinresourcepoorcountries,whereantibiotics
maybehardtocomebyand/orexpensive.

Background
Inflammationofthebulbarand/orpalpebralconjunctiva,orconjunctivitis,canbecausedbyallergies,
viruses,orbacteria.Bacterialconjunctivitisiscommonlycausedbystaphylococci,streptococci,
chlamydialorganism,andgonococci.Mildconjunctivitisisusuallybenignandselflimitedandcanbe
easilytreatedwithantibiotics.Severeconjunctivitis,suchasthatcausedbygonococci,cancause
blindnessandcansignifyasevereunderlyingsystemicdisease.
Thepurposeofthisarticleisto(1)helpthepractitionerrecognizethecharacteristicsandsignificance
ofthecondition,(2)avoidpitfallsindiagnosis,and(3)conveyappropriatetreatmentmodalities.
Conjunctivalscrapingsandculturesarecommonlyusedtoconfirmthemicrobeinsevereandbacterial
conjunctivitisandthatresistanttoantibiotictreatment(seeWorkup).Themainstayoftreatmentof
bacterialconjunctivitisistopicalantibiotictherapy.SystemicantibioticsareindicatedforNeisseria
gonorrhoeaeandchlamydialinfections.Surgicalinterventionisrequiredonlyifthecorneaisinvolved
andresultsincornealopacification(seeTreatment).
Seethefollowingformoreinformation:

AcuteHemorrhagicConjunctivitis

AllergicConjunctivitis

AtopicKeratoconjunctivitis

EmergentTreatmentofAcuteConjunctivitis

EpidemicKeratoconjunctivitis

GiantPapillaryConjunctivitis

KeratoconjunctivitisSicca

NeonatalConjunctivitis

SuperiorLimbicKeratoconjunctivitis

ViralConjunctivitis

Pathophysiology

Thesurfacetissuesoftheeyeandtheocularadnexaarecolonizedbynormalflorasuchasstreptococci,
staphylococci,andCorynebacteriumstrains.Alterationsinthehostdefenseorinthespeciesofbacteria
canleadtoclinicalinfection.Alterationinthefloracanoccurbyexternalcontamination(eg,contact
lenswear,swimming)orspreadfromadjacentinfectioussites(eg,rubbingoftheeyes).
Theprimarydefenseagainstinfectionistheepitheliallayercoveringtheconjunctiva.Disruptionofthis
barriercanleadtoinfection.Secondarydefensesincludehematologicimmunemechanismscarriedby
theconjunctivalvasculature;tearfilmimmunoglobulinsandlysozyme;andtherinsingactionof
lacrimationandblinking.

Etiology
Bacterialconjunctivitismostoftenoccursinotherwisehealthyindividuals.Riskfactorsinclude
frequentexposuretoinfectedindividuals,contactlenswear,sinusitis,immunodeficiencystates,and
exposuretoagentsofsexuallytransmitteddiseaseatbirth.

Epidemiology
Bacterialconjunctivitisiscommonworldwide.Mostbenigncasesaretreatedwithtopicalantibioticsor
canresolvespontaneously.[2]Internationally,isolatedepidemicscanbedevastatinginareasaffectedby
blindinginfectionsofnewborns,especiallyinareasheavilyaffectedbyChlamydiatrachomatis.[3]

Racialandsexualdifferencesinincidence
Bacterialconjunctivitisoccursinpersonsofallraces,althoughdifferencesinfrequenciesmaybe
reflectedbygeographicalvariationsofpathogenprevalence.
Malesandfemaleshaveequalnaturalresistancetobacterialconjunctivitis.Differencesininfection
ratesmayreflectenvironmentalandbehavioralpatterns,suchastheexposureoffemaleelementary
schoolteacherstochildrenaffectedbythecondition.

Agerelateddifferencesinincidence
Ageisarelevantfactorinthesignificanceofbacterialconjunctivitis.Thepractitionermustbevigilant
inconsideringsexuallytransmitteddiseasescausedbyNeisseriagonorrhoeaeandChlamydiain
sexuallyactiveagegroupsandinnewbornswhomayhavebeenexposedduringbirth.Tactfuland
confidentialhistorytakingareanecessaryskillsoasnottoviolatingHIPPAregulations.Inanethical
ormedicolegalsituation,obtainingadvicefromadministrationand/orcolleaguesisrecommended.

Prognosis
Theprognosisforcompleterecoverywithoutsequelaeisexcellentinbacterialconjunctivitis,aslongas
thecorneaisnotinvolved.Complicationsareexpectedtodeveloponlyincasescausedbyextremely
pathogenicbacteria,suchasChlamydiatrachomatisorNgonorrhoeae.
Mortalityinthesettingofbacterialconjunctivitisisrelatedtothefailuretorecognizeandtreatthe
underlyingdisease.SepsisandmeningitiscausedbyNgonorrhoeaecanbelifethreatening.[4]
Chlamydialinfectioninthenewborncanleadtopneumoniaand/orotitismedia. [5]
Signsandsymptomsofdiscomfort,mucopurulentoculardischarge,andconjunctivalrednessare
commoninbenigncasesandoftenleadtoabsencefromworkandschooltominimizeinfectionto

others.Morbiditycanbeassociatedwithmisdiagnosis.Sincemanyeyediseasescausetheeyetobe
red,itisbeneficialtohaveasolidapproachtodiagnosis.