Acute conjunctivitis can be caused by numerous bacteria. Symptoms are hyperemia, lacrimation, irritation, and discharge. Diagnosis is clinical. Treatment is with topical antibiotics, augmented by systemic antibiotics in more serious cases.
Most bacterial conjunctivitis is acute; chronic bacterial conjunctivitis may be caused by Chlamydia and rarely Moraxella. Chlamydial conjunctivitis includes trachoma and adult inclusion conjunctivitis or neonatal inclusion conjunctivitis.
(See also Overview of Conjunctivitis.)
Etiology of Acute Bacterial Conjunctivitis
Bacterial conjunctivitis is usually caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus species, Moraxella catarrhalis or, less commonly, Chlamydia trachomatis. Neisseria gonorrhoeae causes gonococcal conjunctivitis, which usually results from sexual contact with a person who has a genital infection.
Ophthalmia neonatorum (neonatal conjunctivitis) results from a maternal gonococcal and/or chlamydial infection. Neonatal conjunctivitis occurs in approximately 30% of neonates delivered through an infected birth canal (1).
Etiology reference
1. Laga M, Plummer FA, Nzanze H, et al. Epidemiology of ophthalmia neonatorum in Kenya. Lancet. 1986;2(8516):1145-1149. doi:10.1016/s0140-6736(86)90544-1
Symptoms and Signs of Acute Bacterial Conjunctivitis
Symptoms are typically unilateral but frequently spread to the opposite eye within a few days.
Discharge is typically purulent.
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
The bulbar and tarsal conjunctivae are intensely hyperemic and edematous. Petechial subconjunctival hemorrhages, chemosis, photophobia, and an enlarged preauricular lymph node are typically absent. Eyelid edema is often moderate.
With adult gonococcal conjunctivitis, symptoms develop 12 to 48 hours after exposure. Severe eyelid edema, chemosis, and a profuse purulent exudate are typical. Rare complications include corneal ulceration, abscess, perforation, panophthalmitis, and blindness.
DR M.A. ANSARY/SCIENCE PHOTO LIBRARY
Symptoms of gonococcal ophthalmia neonatorum appear 2 to 5 days after delivery or earlier with prelabor rupture of membranes. Symptoms of chlamydial ophthalmia neonatorum appear within 5 to 14 days after birth. Symptoms of both are bilateral, intense papillary conjunctivitis with eyelid edema, chemosis, and mucopurulent discharge.
Diagnosis of Acute Bacterial Conjunctivitis
Ocular examination
Sometimes culture of conjunctival smear or scrapings
Diagnosis of conjunctivitis and differentiation between bacterial, viral, and noninfectious conjunctivitis (see table Differentiating Features in Acute Conjunctivitis) are usually clinical. However, differentiation between bacterial and viral conjunctivitis is often difficult based on clinical criteria because symptoms often overlap.
Smears and bacterial cultures should be done in patients with severe symptoms, immunocompromise, ineffective initial therapy, or a vulnerable eye (eg, after a corneal transplant, in exophthalmos due to Graves disease). Smears and conjunctival scrapings should be examined microscopically and stained with Gram stain to identify bacteria and stained with Giemsa stain to identify the characteristic epithelial cell basophilic cytoplasmic inclusion bodies of chlamydial conjunctivitis (see Adult Inclusion Conjunctivitis).
Differentiating Features in Acute Conjunctivitis
Treatment of Acute Bacterial Conjunctivitis
Topical antibiotics for infections caused by Staphylococcus species, Streptococcus pneumoniae, and Haemophilus influenzae
Systemic antibiotics for gonococcal and chlamydial infection
Bacterial conjunctivitis is very contagious, and standard infection control measures should be followed.
Clinicians avoid transmitting infection if they do the following:
Use hand sanitizer or wash their hands properly (fully lather hands, scrub hands for at least 20 seconds, rinse well, and turn off the water using a paper towel)
Disinfect equipment after examining patients
Patients should do the following:
Use hand sanitizer and/or wash their hands thoroughly after touching their eyes or nasal secretions
Avoid touching the noninfected eye after touching the infected eye
Avoid sharing towels or pillows
Avoid swimming in pools
If one of the more common causes of bacterial conjunctivitis (eg, Staphylococcus species, S. pneumoniae, or H. influenzae) is suspected, most clinicians treat presumptively with a broad-spectrum topical antibiotic (eg, moxifloxacin 0.5% drops or another fluoroquinolone or trimethoprim/polymyxin B 2 to 4 times a day for 7 to 10 days) () is suspected, most clinicians treat presumptively with a broad-spectrum topical antibiotic (eg, moxifloxacin 0.5% drops or another fluoroquinolone or trimethoprim/polymyxin B 2 to 4 times a day for 7 to 10 days) (1). A poor clinical response after 2 or 3 days indicates that the cause is resistant bacteria, a virus, or an allergy. Culture and sensitivity studies should then be done (if not done previously); results direct subsequent treatment.
Gonococcal conjunctivitis is suspected when there is severe eyelid edema and profuse purulent exudate. Because chlamydial genital infection is often present in patients with gonorrhea, adult gonococcal conjunctivitis requires dual therapy. A single dose of ceftriaxone 1 g IM plus azithromycin 1 g orally once (to treat possible chlamydial co-infection [Gonococcal conjunctivitis is suspected when there is severe eyelid edema and profuse purulent exudate. Because chlamydial genital infection is often present in patients with gonorrhea, adult gonococcal conjunctivitis requires dual therapy. A single dose of ceftriaxone 1 g IM plus azithromycin 1 g orally once (to treat possible chlamydial co-infection [trachoma]) or with doxycycline 100 mg orally twice a day for 7 days if ]) or with doxycycline 100 mg orally twice a day for 7 days ifazithromycin allergy. Fluoroquinolones are not recommended because resistance is now widespread. Bacitracin 500 U/g or gentamicin 0.3% ophthalmic ointment instilled into the affected eye every 2 hours may be used in addition to systemic treatment. Sex partners should also be treated. Patients need to be evaluated for other allergy. Fluoroquinolones are not recommended because resistance is now widespread. Bacitracin 500 U/g or gentamicin 0.3% ophthalmic ointment instilled into the affected eye every 2 hours may be used in addition to systemic treatment. Sex partners should also be treated. Patients need to be evaluated for othersexually transmitted infections, and the local public health authorities (at least in the United States) need to be notified.
Routine use of erythromycin ointment instilled into each eye at birth effectively prevents gonococcal ophthalmia but does not prevent chlamydial ophthalmia (see Routine use of erythromycin ointment instilled into each eye at birth effectively prevents gonococcal ophthalmia but does not prevent chlamydial ophthalmia (seePrevention of Neonatal Conjunctivitis). Ophthalmia neonatorum that develops despite this treatment requires systemic treatment. For gonococcal infection, neonates are treated with ceftriaxone or cefotaxime. For chlamydial infection, neonates are treated with erythromycin ethylsuccinate or azithromycin. The parents should also be treated. (See also ). Ophthalmia neonatorum that develops despite this treatment requires systemic treatment. For gonococcal infection, neonates are treated with ceftriaxone or cefotaxime. For chlamydial infection, neonates are treated with erythromycin ethylsuccinate or azithromycin. The parents should also be treated. (See alsoTreatment of Neonatal Conjunctivitis.)
Treatment reference
1. Cheung AY, Choi DS, Ahmad S, et al. Conjunctivitis Preferred Practice Pattern. Ophthalmology. 2024;131(4):P134-P204. doi:10.1016/j.ophtha.2023.12.037
Key Points
Acute bacterial conjunctivitis tends to differ from viral conjunctivitis by the presence of purulent discharge and the absence of chemosis and preauricular adenopathy.
Forms of bacterial conjunctivitis that need to be treated differently include neonatal conjunctivitis, gonococcal conjunctivitis, trachoma, and inclusion conjunctivitis (a type of chlamydial conjunctivitis).
Diagnosis is usually clinical.
Treatment includes measures to prevent spread and antibiotics (topical, such as a fluoroquinolone, for causes except gonococcal and chlamydial).
