Bacterial Conjunctivitis in Adults

Bacterial conjunctivitis in adults is infection of the conjunctiva, most often by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. It is usually self limiting, resolving in 5 to 7 days, but severe forms exist.

• Neisseria gonorrhoeae causes hyperacute, sight threatening disease.
• Chlamydia trachomatis causes chronic follicular conjunctivitis in sexually active adults, and trachoma in endemic areas.
• Contact lens wearers are at risk of Pseudomonas.

Red eye with purulent or mucopurulent discharge, lids stuck together on waking, gritty discomfort, and little pain or visual loss.

• Gonococcal infection causes copious pus, lid swelling and rapid corneal involvement; chlamydial infection causes mucoid discharge and follicles.
• Differential diagnosis: viral conjunctivitis, allergic conjunctivitis, keratitis, acute anterior uveitis, acute angle closure, dacryocystitis, blepharitis, foreign body, herpetic eye disease.
• Complications: corneal ulcer and perforation (gonococcus, Pseudomonas), scarring, trachoma and trichiasis, preseptal cellulitis, endophthalmitis.

Clinical diagnosis, with swab for severe or atypical disease.

• Conjunctival swab for Gram stain and culture in hyperacute, neonatal, contact lens related, recurrent or treatment failure disease.
• Nucleic acid amplification test for chlamydia and gonococcus from the conjunctiva and genital sites.
• Slit lamp examination with fluorescein to exclude corneal ulcer.

Topical antibiotics shorten the course; severe disease needs systemic therapy.

• Supportive: bathe the eyelids with clean cooled boiled water to remove discharge, hand washing, avoid sharing towels, avoid contact lenses and make up, stay off work until discharge settles.
• Pharmacological: chloramphenicol 0.5 percent drops, one drop every 2 hours for 2 days and then four times daily for 5 days, with chloramphenicol 1 percent ointment at night; or fusidic acid 1 percent gel twice daily for 7 days; or ofloxacin 0.3 percent drops four times daily for 7 days. Contact lens wearers: ofloxacin 0.3 percent or moxifloxacin 0.5 percent drops every 2 hours initially. Gonococcal: ceftriaxone 1 g IM single dose with azithromycin 1 g orally, and saline irrigation of the eye; refer urgently. Chlamydial: azithromycin 1 g single dose, or doxycycline 100 mg twice daily for 7 days. Trachoma: azithromycin 1 g single dose and tetracycline 1 percent ointment twice daily for 6 weeks.
• Procedures: lid eversion and irrigation in gonococcal disease; surgery for trichiasis.
• Special groups: pregnancy, chloramphenicol drops, erythromycin ointment and azithromycin for chlamydia, avoid doxycycline; sexual partners, treat for gonococcus and chlamydia; infants, systemic therapy.
• Red flags: pain, reduced vision, photophobia, corneal opacity, copious pus, lid swelling, contact lens wear, no improvement in 48 hours.
• Follow-up: review at 48 hours if gonococcal or severe; otherwise at 1 week.