Diagnosing and treating infectious conjunctivitis is relatively routine, but the costs to the family and society can be significant. Currently, no uniform conjunctivitis treatment protocols for managing acute infectious conjunctivitis in children exist, and according to the American Academy of Pediatrics, the role of antibiotics is unclear.1-3
Acute conjunctivitis — an eye condition most commonly treated by pediatric, family medicine, urgent care, and nurse practitioners, not optometrists or ophthalmologists — is estimated to represent approximately 1% of all consultations in primary care.1,2 A total of 70% of adult conjunctivitis cases are the result of an adenovirus, while approximately 50% of pediatric cases may be due to bacteria.3
While treatment strategies may vary between clinicians, a 2022 study highlights clinical presentation, diagnostic uncertainty, direct and indirect costs, and societal pressure as some of the most important figures to consider when treating a pediatric case of infectious conjunctivitis.3
Differences in clinical presentation can allow the clinician to reach an accurate diagnosis. Viral conjunctivitis is the most common infectious conjunctivitis, it is self-limiting, and usually does not require treatment.4 It often has an abrupt onset, occurs either unilaterally or bilaterally, and can vary in severity.
The signs and symptoms at presentation may vary — bulbar conjunctival injection, watery discharge, follicles, conjunctival chemosis, eyelid swelling, and erythema are common. Additional clinical signs may include preauricular lymphadenopathy, petechial and subconjunctival hemorrhage, corneal epithelial defects, and punctate keratitis.5 In many cases, the child has a history of exposure to another infected individual or may have an upper respiratory infection.
Bacterial conjunctivitis is the second most common cause of infectious conjunctivitis, and most cases resolve in 1 to 2 weeks without treatment.4 Bacterial conjunctivitis is characterized by a purulent eye discharge, sticky eyes on awakening, foreign body sensation, and conjunctival injection. Clinical signs alone allow the clinician to reach a diagnosis, as cultures cannot influence treatment decisions and are not cost-effective.5,6
Overall, clinical practice lacks uniformity in distinguishing viral from bacterial conjunctivitis.3 However, making this distinction is crucial, as it will affect management strategy, according to Alan Kabat, OD, an adjunct professor at Salus University and a clinical specialist in anterior segment disorders. “The decision to prescribe should be based first and foremost upon an accurate diagnosis of bacterial conjunctivitis; the most common viral vectors of infectious conjunctivitis are simply not affected by antibiotic agents,” he said.
General practitioners face a great challenge in accurately diagnosing acute conjunctivitis, which often leads to them prescribing an antibiotic cover. While 40% to 50% of conjunctivitis cases are caused by bacteria, antibiotics are prescribed in more than 70% of pediatric cases.1 A good medical history assessment, which involves asking patients and parents about all symptoms, symptom duration, recent exposure to infected individuals, recent illnesses, and previous episodes of conjunctivitis is helpful for diagnosis.5
While viral cultures are not routinely used for diagnosis, they may prevent viral spread and unnecessary antibiotic use. A rapid, in-office immunodiagnostic test using antigen detection is available for adenovirus conjunctivitis. While the test demonstrated high sensitivity (88-89%) and specificity (91-94%) in a small study of patients (n=186), it has not been validated in pediatric patients.3,5
Children who present to pediatric clinics or receive a telemedical evaluation are more likely to be prescribed antibiotics than children seeking care at a family medicine, optometry, or ophthalmology clinic.7
Direct and Indirect Costs
Clinicians must consider direct and indirect costs involved with treating conjunctivitis. The family incurs the direct costs of an office visit and medications, and the indirect cost of missed work for the parents. One study estimates the cost of caring for conjunctivitis ranges between $377 and $857 million per year.1
Clinicians may experience pressure from parents to prescribe a medication for the child’s conjunctivitis, and it may even be required by the child’s school. In cases of adenoviral conjunctivitis, parents and school administrators should be educated that antibiotic drops are often unnecessary and that spread at schools is rare.1
In cases where antibiotic treatment is unwarranted, Dr Kabat recommends a letter or phone call to alleviate any pushback. “I will explain that employing a topical antibiotic for viral conjunctivitis is an unnecessary expense since it only affects bacterial pathogens. Furthermore, in some cases it can actually worsen or extend the clinical course of the disease, because some antibiotics are known to be corneotoxic. I tend not to worry much about bacterial resistance, since, although the creation of resistant superbugs is both real and concerning with regard to systemic antibiotics, the limited amount and localization of these drugs in ophthalmic form are, to put it colloquially, a drop in the ocean,” he said.
Nonetheless, research shows that increased antibiotic resistance remains a substantial concern when prescribing systemic antibiotics.8
Evidence-Based Conjunctivitis Treatments
Since conjunctivitis is often self-limiting, patient education should focus on preventing its spread and managing symptoms. Proper hygiene practices are imperative — children, and members of their household, must wash their hands frequently, use separate towels, and avoid close contact with others while contagious.
When topical antibiotic use for bacterial conjunctivitis is indicated, treatment with aminoglycosides (gentamicin, tobramycin, neomycin and framycetin), fluoroquinolones (ciprofloxacin, ofloxacin and norfloxacin), sulfacetamide, chloramphenicol, or erythromycin may be used. Clinicians may also treat with a combination of agents, including neomycin and polymyxin with bacitracin or gramicidin, or polymyxin and trimethoprim with bacitracin or gramicidin. There are few clinical trials that compare the performance of 2 or more antimicrobial agents and no evidence exists demonstrating the superiority of any topical antibiotic agent.5,9
Polytrim is also a popular bacterial conjunctivitis treatment — a 2013 study evaluated its efficacy and safety compared with moxifloxacin among pediatric patients and deemed that it efficaciously treated acute conjunctivitis while significantly reducing treatment costs.10 Study participants received 1 drop in the affected eye or eyes every 3 hours for 7 to 10 days.10
Canaan Montgomery, OD, of West End Eye Care in Paducah, KY treats a large number of pediatric patients in his practice and prescribes both polytrim and erythromycin ointment. “The ointment is better for really young children or if parents aren’t confident that they can easily instill an eye drop,” he said.
Dr Kabat expressed his preferential treatment for bacterial conjunctivitis. “I have always been partial to moxifloxacin, because of its broad spectrum and low potential for toxicity, but have also successfully used besifloxacin, gatifloxacin and ofloxacin. Some eye care practitioners prefer to use a polymyxin B plus trimethoprim fixed combination drop in pediatric patients, and this is certainly another good option. However, I tend to avoid aminoglycosides as they can be quite detrimental to the corneal integrity,” he said.
Supportive therapies, including lid hygiene for sticky eyelids, cool compresses, and artificial tears, can also improve symptoms in pediatric patients.9 Children who are photophobic should also avoid exposure to bright lights.9 Dr Kabat said that he sometimes recommends oral analgesics such as acetaminophen or ibuprofen in addition to supportive therapies to ease his patients’ discomfort. For bacterial conjunctivitis, he emphasized the importance of clearing away the mucopurulent discharge from the eyes and lids and “liberally rinsing with warm, sterile saline [to] provide relief and enhance recovery.”
While antibiotic use is not always indicated with conjunctivitis, they can provide symptomatic relief and are safe when used appropriately. “In general, most topical ophthalmic antibiotics are safe to prescribe, even in pediatric patients as young as a year old,” according to Dr Kabat. “Of course, one must always thoroughly explore the history for potential allergies to medication and related substances. Rare and serious reactions to seemingly innocuous medications, such as Stevens-Johnson syndrome, can occur even with topical antibiotics. The age of the child and their level of cooperation with regard to instillation of drops should also be taken into account when selecting a regimen.”
Topical antibiotics can reduce patient symptoms, shorten the duration of the condition, and allow children to return to school sooner.4 A 2013 study showed that children experienced clinical resolution more rapidly with moxifloxacin compared with a placebo treatment (3.8 vs 5.7 days; 95% CI, −3.7 to −0.1 days; P =.04).11 There was also a significant reduction in the number of children with conjunctivitis symptoms on days 3 to 6 when treated with a topical antibiotic compared with placebo eye drops.11
Clinicians are often aware of antibiotic resistance and consider it when prescribing antibiotics. It has become problematic and been attributed to a decrease in the effectiveness of many ophthalmic antibiotics, a 2022 study shows.3 Other investigations performed in vitro shows that staphylococcus aureus and coagulase-negative staphylococci (CoNS) are highly resistant to fluoroquinolones, macrolides methicillin, and oxacillin, — high multidrug resistance rates were noted, particularly with methicillin-resistant staphylococci.12,13
Policy for School Return
Since school return policies following infection will vary from state to state, a clinician should familiarize themselves with their states’ specific policy. A total of 10 states allow students to remain in school, 5 allow children to return 24 hours after initiating antibiotic treatment, and 5 require clearance from a physician.8 Washington, DC and 17 states provide few or inconsistent recommendations, 12 states have thorough policies, and 15 states do not have any policy, a 2022 investigation found.8
Twenty-three states suggest following Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP) recommendations. Both organizations recommend supportive care for viral conjunctivitis and topical antibiotics for bacterial conjunctivitis, but stress that treatment decisions should be left to the doctor.14,15
Professional optometry associations must take the lead, set the record straight, and establish a precedent for treating conjunctivitis, according to Dr Kabat.“The American Optometric Association publishes clinical practice guidelines periodically for a variety of common clinical disorders; unfortunately, the guidelines for conjunctivitis were last updated in 2002, more than 20 years ago. The American Academy of Ophthalmology’s Preferred Practice Patterns® for conjunctivitis were updated much more recently, in 2018. Optometry needs to make an effort to revise its guidelines for the profession by revisiting this topic with top leaders in anterior segment disease management. If the organization is not willing or able to undertake this effort, then an independent advisory panel should do so, and publish their consensus report in a high-quality, peer-reviewed, and indexed journal. If optometrists truly envision themselves as the gatekeepers of eye and vision care, then we need to be leading the discussion on matters like these” he said.
Dr Montgomery agreed. “Optometry should absolutely take the lead in establishing clinical guidelines for treatment of infectious conjunctivitis in children. The responsibility for treating these conditions shouldn’t fall to the pediatricians, ERs, and other family medicine practitioners who don’t have the means or experience to examine the eye with a slit-lamp.”
However, until uniform, evidence-based standards are established, clinicians must continue to follow the guidance of their state, the CDC, and the AAP.14,15
Disclosure: Alan Kabat, OD, FAAO, is Senior Medical Director at Oyster Point Pharmaceuticals. The opinions expressed herein by Dr. Kabat are solely his and do not necessarily reflect the opinions of Oyster Point.
- Fredrick D. Acute conjunctivitis in children: a sticky issue itching for some answers. J AAPOS. 2022;26(3):107-108. doi:10.1016/j.jaapos.2022.04.001
- Høvding G. Acute bacterial conjunctivitis. Acta Ophthalmol. 2008;86(1):5-17. doi:10.1111/j.1600-0420.2007.01006.x
- Sebastian T, Frost HM. A qualitative evaluation of pediatric conjunctivitis medical decision making and opportunities to improve care. J AAPOS. 2022;26(3):113.e1-113.e6. doi:10.1016/j.jaapos.2021.12.008
- Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721-1729. doi:10.1001/jama.2013.280318
- Varu DM, Rhee MK, Akpek EK, et al. Conjunctivitis preferred practice pattern®. Ophthalmol. 2019;126(1):P94-P169. doi:10.1016/j.ophtha.2018.10.020
- Leung AKC, Hon KL, Wong AHC, Wong AS. Bacterial conjunctivitis in childhood: etiology, clinical manifestations, diagnosis, and management. Recent Pat Inflamm Allergy Drug Discov. 2018;12(2):120-127. doi:10.2174/1872213X12666180129165718
- Frost HM, Sebastian T, Durfee J, Jenkins TC. Ophthalmic antibiotic use for acute infectious conjunctivitis in children. J AAPOS. 2021;25(6):350.e1-350.e7. doi:10.1016/j.jaapos.2021.06.006
- Lee T, Kuo IC. Survey of state conjunctivitis policies for school-age students. J AAPOS. 2022;26(3):115.e1-115.e5. doi:10.1016/j.jaapos.2022.02.002
- Chawla R, Kellner JD, Astle WF. Acute infectious conjunctivitis in childhood. Paediatr Child Health. 2001;6(6):329-335. doi:10.1093/pch/6.6.329
- Williams L, Malhotra Y, Murante B, et al. A single-blinded randomized clinical trial comparing polymyxin B-trimethoprim and moxifloxacin for treatment of acute conjunctivitis in children. J Pediatr. 2013;162(4):857-861. doi:10.1016/j.jpeds.2012.09.013
- Honkila M, Koskela U, Kontiokari T, et al. Effect of topical antibiotics on duration of acute infective conjunctivitis in children: A randomized clinical trial and a systematic review and meta-analysis. JAMA Netw Open. 2022;5(10):e2234459. doi:10.1001/jamanetworkopen.2022.34459
- Bispo PJM, Sahm DF, Asbell PA. A systematic review of multi-decade antibiotic resistance data for ocular bacterial pathogens in the United States. Ophthalmol Ther. 2022;11(2):503-520. doi:10.1007/s40123-021-00449-9
- Thomas RK, Melton R, Asbell PA. Antibiotic resistance among ocular pathogens: current trends from the ARMOR surveillance study (2009-2016). Clin Optom (Auckl). 2019;11:15-26. doi:10.2147/OPTO.S189115
- Conjunctivitis (Pink Eye). Centers for Disease Control and Prevention. Updated January 4, 2019. Accessed February 10, 2023. https://www.cdc.gov/conjunctivitis/about/treatment.html.
- Kneen, L. Red Eye/ Pink eye. Point-of-care quick reference. American Academy of Pediatrics. Updated August 12, 2022. Accessed February 10, 2023. https://publications.aap.org/pediatriccare/article-abstract/doi/10.1542/aap.ppcqr.396107/1547/Red-Eye-Pinkeye