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Infectious conjunctivitis 

Updated 2013 Apr 03 02:01:00 PM: polymyxin B-trimethoprim may be as effective as moxifloxacin for cure of acute conjunctivitis in children (J Pediatr 2013 Apr) view updateShow more updates

Related Summaries:  

Allergic conjunctivitis Vernal conjunctivitis

General Information Description:  

superficial infection, hyperemia of conjunctival blood vessels not usually serious but can be highly contagious

Types: 

viral conjunctivitis o nonspecific follicular conjunctivitis  usually caused by adenovirus serotypes 1-11  self-limiting  more common in children  often associated with upper respiratory infection  duration of disease 3-7 days (5)  Reference - Postgrad Med 1997 May;101(5):185, o pharyngoconjunctival fever  caused by adenovirus  more often unilateral  more often in children  associated with pharyngitis and fever  duration usually 2 weeks  5% risk of persistent morbidity  Reference - Int Ophthalmol Clin 1984 Summer;24(2):49 o hemorrhagic conjunctivitis  most common cause is adenovirus, but can also be caused by enterovirus 70, coxsackievirus and echovirus  petechial hemorrhages on bulbar conjunctivae  highly contagious  usually complete recovery over 3 weeks


outbreak of acute hemorrhagic conjunctivitis due to coxsackievirus A24 reported in Puerto Rico 2003 with estimated 490,000 cases (MMWR Morb Mortal Wkly Rep 2004 Jul 23;53(28):632 ) (5) o epidemic keratoconjunctivitis (EKC)  highly contagious, usually caused by adenovirus serotypes 8, 19, 37  patients develop significant chemosis, pseudomembranes and keratitis  duration may last 3-4 weeks  30-50% risk of developing chronic dry eye or persistent corneal deposits with light sensitivity and vision loss  wash office area (including doorknobs) after contact with 10% bleach solution  avoid shaking hands with affected patients  26 patients with culture-proven EKC and 26 control patients had conjunctivae and hands cultured  46% EKC patients vs. no controls had positive hand cultures for adenovirus  Reference - Am J Ophthalmol 1996 Jun;121(6):711 o herpes simplex virus (HSV) conjunctivitis  may present similarly to adenovirus  4-5% viral conjunctivitis due to HSV without associated skin lesions  usually unilateral  Reference - Br J Ophthalmol 2000 Sep;84(9):968 PDF bacterial conjunctivitis(1) o acute  defined as conjunctivitis with duration ≤ 3-4 weeks  most common form of bacterial conjunctivitis seen by primary care clinicians o hyperacute  abrupt onset  profuse thick, yellow-green purulent discharge  ocular injection and chemosis  inflammatory membrane may form  Neisseria gonorrhoeae is most common pathogen o chronic  conjunctivitis with symptoms for ≥ 4 weeks  discharge and hyperemia typically mild-moderate  coagulase-positive and coagulase-negative staphylococci are most common pathogens  relapse is common  chlamydial conjunctivitis may also be frequent cause of chronic conjunctivitis (Ophthalmologica 1997;211 Suppl 1:25, Eur J Epidemiol 1990 Sep;6(3):300)

Organs involved: 

conjunctiva, unilateral may be bacterial, bilateral more commonly viral


Incidence/Prevalence:   

acute conjunctivitis accounts for about 1% of all primary care visits in Norway(1) 1.33% prevalence of conjunctivitis among United States population aged 1-74 years in 1971-1972 (Vital Health Statistics 1983 Mar;11:228 PDF) 41% of general practice consultations for eye problems are for infective conjunctivitis o based on 1-year survey of 23 physicians in 12 general practices in west of Nottingham o 1,630 consultations recorded for new or newly recurrent ophthalmic disease (45.3 per 1,000 population per year) o 41.1% of these consultations were for infective conjunctivitis o Reference - Br J Gen Pract 1993 Nov;43(376):459 PDF) incidence in United States Navy recruits 1.1 per 1,000 recruits per week o based on 23 cases during 4-week study o Reference - Mil Med 1990 Jan;155(1):1 neonatal conjunctivitis occurs in 3 cases per 1,000 live births o based on 171 cases at 1 hospital over 26 years o Reference - Ann Ophthalmol 1981 Mar;13(3):329

Causes and Risk Factors Causes: 

viral conjunctivitis o adenovirus serotypes 8, 19 and 37 are common causes o adenovirus serotypes 3 and 7 cause pharyngoconjunctival fever (5) o < 5% of United States population have immunity against adenovirus o adenoviral conjunctivitis represents 20%-62% infectious conjunctivitis  adenovirus found in 20% of 99 patients with acute conjunctivitis in pediatric practice (J Pediatr 1981 Apr;98(4):531)  adenovirus found in 62% of 50 patients with acute infectious conjunctivitis presenting to an emergency room July-October 2003 who had polymerase chain reaction testing (Optometry 2007 May;78(5):236) acute bacterial conjunctivitis o staphylococci and streptococci most common in adults o Haemophilus influenzae and Streptococcus pneumoniae (pneumococcus) most common cause in children(1, 2) o H. influenzae and pneumococcus common in conjunctivitis in young children  based on prospective cohort study  conjunctival swabs taken from 428 children aged 2-36 months  55% were positive for at least 1 pathogen including  29% positive for H. influenzae  20% positive for S. pneumoniae  Reference - Pediatr Infect Dis J 2005 Sep;24(9):823


o

pneumococcal conjunctivitis outbreaks reported in multiple settings  Reference - MMWR Morb Mortal Wkly Rep 2003 Jan 31;52(4):64 in JAMA 2003 Mar 5;289(9):1097  including large outbreak on a college campus (N Engl J Med 2003 Mar 20;348(12):1112 ), commentary can be found in N Engl J Med 2003 Jun 19;348(25):2577 neonatal conjunctivitis o gonococci - ophthalmia neonatorum o Chlamydia trachomatis serovars D-K - inclusion conjunctivitis  Chlamydia trachomatis detected in 61-64% infants < 3 months old with conjunctivitis  based on analysis of 2 cohorts (1 retrospective and 1 prospective)  Reference - Pediatrics 2008 Feb;121(2):e321 o herpes simplex virus (HSV) o neonatal conjunctivitis usually bacterial or chlamydial (Ann Ophthalmol 1981 Mar;13(3):329, Acta Ophthalmol (Copenh) 1984 Jun;62(3):461, Eur J Pediatr 1987 Mar;146(2):152)

Pathogenesis: 

risk of transmission based on systematic literature review (data based mainly on adenoviruses) o low/moderate risk of transmission (< 10%-30%) o incubation period 3-29 days (mean 11 days), based on limited evidence o duration of shedding not known (no evidence found) o period of infectiousness up to 2 weeks, based on limited evidence o serial interval (interval between onset of clinical disease in index case and secondary case) not known (no evidence found) o Reference - Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184 period of infectiousness may vary with adenoviral serotype o based on retrospective chart review an in vitro infectivity titers of 90 clinical ocular adenoviral isolates o positive cultures in second week of disease reported for  adenovirus serotype 8 in 9 of 33 (27%) patients  other adenoviral serotypes in 2 of 54 (4%) patients o Reference - Cornea 1995 Jul;14(4):388 adenovirus may remain active or infectious on hard surfaces for up to 4-5 weeks (Ophthalmology 1990 Nov;97(11):1450, Ophthalmology 1993 Dec;100(12):1835)

Possible risk factors: 

risk factors for viral conjunctivitis may include(5) o overcrowding or close quarters o urban setting


o exposure to infected persons nosocomial epidemics of adenoviral conjunctivitis in large teaching eye institutions have been associated with use of tonometer by ophthalmic clinicians (Trans Am Ophthalmol Soc 1996;94:539 PDF) multi-use eye drops o multidose eyedrop bottles used by patients with adenoviral keratoconjunctivitis frequently infected with adenovirus  based on cohort of 26 patients with adenoviral keratoconjunctivitis  19 eyedrop bottles (73%) testing positive for adenovirus  adenovirus detect for up to 9 weeks  Reference - Am J Ophthalmol 2002 Oct;134(4):618 o preservative-free eye drops may become contaminated after 3-7 days  study of 95 multiple use preservative-free eye drop containers (10 different types) collected after 3 days for inpatients and 7 days for outpatients  8.4% rate of bacterial contamination  contamination rates were 60% for eye drops containing hypromellose and 21% for steroid eye drops  Reference - Br J Ophthalmol 2006 Feb;90(2):139 all eye drops and eye/ear wash products from NuCel Labs voluntarily recalled due to possible risk of infections due to non-sterility (FDA MedWatch 2008 Jan 31)

Complications and Associated Conditions Complications: 

 

subepithelial keratitis(5) o can cause light sensitivity or vision loss lasting months to years o develops in 30%-50% patients with epidemic keratoconjunctivitis and 5% pharyngoconjunctival fever conjunctival scarring can lead to dry eyes (5) neurologic complications reported after acute viral hemorrhagic conjunctivitis in case series (Trop Geogr Med 1986 Sep;38(3):197, J Neurol Sci 1986 Apr;73(2):177) lacrimal excretory obstruction causing persistent tearing after acute phase of epidemic keratoconjunctivitis in report of 3 cases (Ophthalmology 1988 Oct;95(10):1447) symblepharon formation (adhesion of eyelid to eye) in epidemic keratoconjunctivitis in report of 2 cases (Cornea 1990 Oct;9(4):338)

Associated conditions: 

conjunctivitis-otitis syndrome may occur in 16% of patients with otitis media o based on case series of 2,901 children aged 6 to 36 months old with otitis media o 16% had purulent conjunctivitis o Reference - Pediatr Infect Dis J 2005 Aug;24(8):731


History and Physical History: Chief concern (CC): 

 

traditional symptoms related to viral conjunctivitis o redness o watery to mucoid discharge in 50%, purulent discharge in 50% o foreign body sensation in 50% o burning and itching in 30-40% (5) o Reference - , J Pediatr 1981 Apr;98(4):531 symptoms reported with acute bacterial conjunctivitis in 2 randomized trials (1) o purulent discharge in 85%-90% o sticky eyelids in 90% o itching and sensation of foreign body in 90% o burning and stinging in 50% red eye or eye pain uncommon except with acute gonococcal conjunctivitis usually no blurred vision, pain, photophobia or colored halos

History of present illness (HPI): 

  

viral conditions may be more associated with o watery to mucoid discharge o recent upper respiratory symptoms o exposure to sick contact o started in 1 eye, then second eye 2-3 days later bacterial conditions may be more associated with o purulent discharge o crusting of lids in morning o acute otitis media allergic conjunctivitis associated with itching as main complaint exudation more severe in bacterial, moderate in viral, least in allergic conjunctivitis in children, infections can mimic preseptal and orbital cellulitis o 13 of 80 (16%) patients with signs of preseptal or orbital infection were culture positive for adenovirus (Pediatr Infect Dis J 1996 Mar;15(3):266) o case report of chlamydial conjunctivitis presenting as preseptal cellulitis in 15-year-old girl can be found in Head Face Med 2007 Mar 14;3:16 in adults, 3 factors in clinical history may differentiate bacterial from viral conjunctivitis o factors associated with bacterial conjunctivitis  early morning glued eye(s)  absence of itching  absence of history of conjunctivitis o cohort study of 184 consecutive adults presenting with red eye and either purulent discharge or glued eyelid to 9 general practitioners at 25 Dutch health centers


patients were excluded if wearing contact lenses, symptoms > 7 days, acute loss of vision, use of antibiotics in previous 2 weeks, ciliary redness, eye trauma, or history of eye surgery  177 (96%) analyzed with complete history and bacterial culture, 2 refused to participate, 3 did not have complete history, 2 did not have culture results  57 (32%) had positive bacterial cultures, of which 27 (47%) were Streptococcus pneumoniae  clinical score for prediction of bacterial conjunctivitis  5 points if 2 glued eyes, 2 points if 1 glued eye  -1 point if itching  -2 points if history of conjunctivitis  score ranges from +5 to -3  score cut-off point of +2 would identify 40% of cohort with 67% sensitivity, 73% specificity, 54% positive predictive value and 82% negative predictive value o Reference - BMJ 2004 Jul 24;329(7459):206 , commentary can be found in BMJ 2004 Sep 11;329(7466):625, and Am Fam Physician 2004 Dec 1;70(11):2201 in children, clinical factors may differentiate bacterial from viral conjunctivitis o 4-factor prediction rule may identify children at low risk of bacterial conjunctivitis  based on prospective cohort study without independent validation  368 children aged 6 months to 17 years (median age 3 years) presenting to emergency department with conjunctival erythema and/or eye discharge were assessed with checklist of conjunctivitis signs and symptoms  reference standard was bacterial culture from conjunctival swab  patients excluded for eye trauma, noxious chemical exposure, contact lens use or antibiotics within 5 days  35.3% of children had negative culture  4 predictive factors were significantly associated with low risk of positive culture  age ≥ 6 years  presentation in April through November  no discharge or watery discharge  no glued eye in morning  presence of 3-4 positive factors associated with high probability of negative culture in analysis of 360 children  probability of negative culture  92.3% (95% CI 66.1%-98.2%) for 4 factors present  76.4% (95% CI 63.6%-85.6%) for 3 factors present  45.8% (95% CI 35.5%-56.5%) for 2 factors present  21.1% (95% CI 15%-28.8%) for 1 factor present  11.8% (95% CI 6.4%-21%) for no factors present


authors note that study was done in area where there is significant seasonal variation in the cause of conjunctivitis and results might not be applicable elsewhere  Reference - Arch Pediatr Adolesc Med 2010 Mar;164(3):263 o in children, bacterial conjunctivitis associated with gluey or sticky eyes in the morning and mucoid or purulent discharge  based on prospective cohort study in convenience sample  111 children aged 2 months to 18 years (mean age 33 months) with diagnosis or symptoms of conjunctivitis in emergency department had conjunctival swab collected for bacterial culture  bacterial culture positive in 78%  nontypeable Haemophilus influenzae in 82%  Streptococcus pneumoniae in 16%  Staphylococcus aureus in 2.2%  positive bacterial culture associated with  history of  gluey or sticky eyes in morning (p = 0.003) (independent risk factor)  mucoid or purulent discharge (p = 0.003)  absence of burning sensation (p = 0.031)  findings on physical exam  mucoid or purulent discharge (p = 0.011) (independent risk factor)  eyelid crusting or gluing (p = 0.017)  absence of watery discharge (p = 0.011)  combination of gluey or sticky morning eyes and presence of mucoid or purulent discharge predictive of bacterial conjunctivitis with 85% sensitivity and 73% specificity  Reference - Acad Emerg Med 2007 Jan;14(1):1, commentary can be found in Acad Emerg Med 2007 Aug;14(8):759 no evidence found on diagnostic usefulness of symptoms or signs for differentiating bacterial from viral conjunctivitis in earlier systematic review (BMJ 2003 Oct 4;327(7418):789), commentary can be found in J Fam Pract 2004 Feb;53(2):105 clinical diagnosis of etiology (viral vs. bacterial) correlates poorly with laboratory tests o based on cohort of 143 patients (207 eyes) with conjunctivitis or blepharoconjunctivitis o only 31% of presumed bacterial conjunctivitis was culture positive o 52% of presumed viral conjunctivitis was culture positive for pathogenic bacteria o Reference - Arch Ophthalmol 1976 Oct;94(10):1747

Physical: HEENT: 

injection of conjunctiva, chemosis (swelling of conjunctiva) if severe


   

conjunctival injection is prominent in bacterial, moderate in viral, least in allergic conjunctivitis pupil, anterior chamber depth and intraocular pressure are normal preauricular lymph node may be present in viral conjunctivitis no evidence found on diagnostic usefulness of symptoms or signs for differentiating bacterial from viral conjunctivitis in systematic review (BMJ 2003 Oct 4;327(7418):789) pictures of conjunctivitis can be found in Adv Stud Med 2006 Sep;6(8):373 PDF

Diagnosis Making the diagnosis: 

clinical presentation which may include o conjunctival injection (red eye) o ocular itching o ocular discharge o sticky eyelids in morning clinical factors cannot reliably differentiate viral from bacterial causes

Rule out:      

allergic conjunctivitis - usually bilateral, history of atopy, prominent itching vernal conjunctivitis - severe, granular, red, allergic, bilateral in young boys acute glaucoma(1) acute iridocyclitis(1) keratitis(1) reaction to ophthalmic decongestants o report of 70 patients with conjunctivitis (both acute and chronic) related to nonprescription ophthalmic decongestants (such as Vasocon, Visine) o conjunctivitis takes nearly 2 months (1-6 months) to resolve after eye drops discontinued o some patients required topical steroids o Reference - Arch Ophthalmol 1997 Jan;115(1):34 see also Red eye - differential diagnosis

Testing overview: 

rapid point-of-care assays (such as AdenoPlus) are sensitive and specific for adenovirus in patients with suspected acute viral conjunctivitis (level 1 [likely reliable] evidence) conjunctival smear not necessary unless severe purulence or gonococci suspected

Other diagnostic testing: Adenoviral rapid test:


rapid point-of-care assays are sensitive and specific for adenovirus in patients with suspected acute viral conjunctivitis (level 1 [likely reliable] evidence) o based on 2 diagnostic cohort studies o AdenoPlus is sensitive and specific for adenovirus in patients with suspected acute viral conjunctivitis (level 1 [likely reliable] evidence)  based on diagnostic cohort study  AdenoPlus is second generation test with modifications to sampling pad and test strip from RPS Adeno Detector  128 patients with clinical diagnosis of acute viral conjunctivitis from 8 ophthalmology practices had 3 tear specimens obtained (5 minutes after ocular anesthetic)  first sample collected with AdenoPlus sample collector (8-10 dabs across conjunctiva, then maintain contact for 3 seconds), results interpreted by masked personnel after 10 minutes  second sample collected with Dacron-tipped swab for viral cell culture with confirmatory immunofluorescence assay (CC-IFA)  third sample collected with Dacron-tipped swab for polymerase chain reaction (PCR)  36 patients (28%) had adenoviral conjunctivitis based on positive CC-IFA and/or positive PCR  compared to CC-IFA (which detected 31 cases of adenoviral conjunctivitis), AdenoPlus had  sensitivity 90%  specificity 96%  positive predictive value 88%  negative predictive value 97%  Reference - JAMA Ophthalmol 2013 Jan;131(1):17 o RPS Adeno Detector appears to have sufficient diagnostic accuracy for in-office use for detecting adenoviral conjunctivitis (level 1 [likely reliable] evidence)  based on diagnostic cohort study  186 patients with suspected acute conjunctivitis seeking treatment within 1 week of red eye were tested with  RPS Adeno Detector - a 10-minute in-office immunoassay  viral cell culture with confirmatory immunofluorescence staining and polymerase chain reaction  using polymerase chain reaction as reference standard  RPS Adeno Detector had 89% sensitivity and 94% specificity  immunofluorescence staining had 91% sensitivity and 100% specificity  Reference - Ophthalmology 2006 Oct;113(10):1758 o DynaMed commentary -- clinical impact and cost-effectiveness not directly established

Conjunctival smear (microscopy):


conjunctival smear may reveal o Gram-negative intracellular diplococci in gonorrhea o intracellular inclusion bodies with Chlamydia o polymorphonuclear leukocytes and bacteria if bacterial o lymphocytes if viral o eosinophils if allergic

Treatment Treatment overview:   

 

stop contact lens use until resolved acute conjunctivitis frequently self-limited in both children and adults, but antibiotics may hasten recovery in bacterial cases (level 2 [mid-level] evidence) delayed antibiotics may allow for spontaneous resolution and associated with reduced duration of symptoms and reduced re-attendance rate (level 2 [mid-level] evidence) topical antibiotics improve rate of early clinical remission in patients with acute bacterial conjunctivitis (level 1 [likely reliable] evidence) ophthalmic antibiotics for bacterial conjunctivitis include o 10% sodium sulfacetamide topical drops or ointment 4 times daily for 1 week o polymyxin B plus trimethoprim (Polytrim) every 3-4 hours for 7-10 days o erythromycin ointment 4 times daily for 1 week o fluoroquinolones (see below for dosing) - besifloxacin (Besivance), ciprofloxacin (Ciloxan), gatifloxacin (Zymar), moxifloxacin (Vigamox), ofloxacin (Ocuflox) o azithromycin 1% (AzaSite) 1 drop twice daily for 2 days then 1 drop once daily for 5 days in United States o azithromycin 1.5% (Azyter) eye drops 1 drop twice daily for 3 days in Europe o tobramycin or gentamicin topical drops 4 times daily for 1 week povidone-iodine 1.25% ophthalmic solution (dilute Betadine) 1 drop 4 times daily may be as effective as neomycin-polymyxin B-gramicidin for infectious conjunctivitis in children (level 2 [mid-level] evidence) Centers for Disease Control and Prevention recommendations for gonococcal and chlamydial conjunctivitis o gonococcal conjunctivitis  for adults, ceftriaxone 1 g intramuscularly once  for infants, ceftriaxone 25-50 mg/kg (maximum 125 mg) IV or intramuscularly as single dose o chlamydial conjunctivitis  for children who weigh < 45 kg including neonates, erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days  for children aged < 8 years old who weigh ≥ 45 kg, azithromycin 1 g orally in a single dose


for children aged ≥ 8 years old and adults, azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days ketorolac eye drops do not appear effective for viral conjunctivitis (level 2 [midlevel] evidence) follow-up if symptoms continue after treatment 

 

Activity:  

isolation (for example, avoiding day care) often recommended for 5-7 days with viral conjunctivitis (grade C recommendation [lacking direct evidence]) period of infectiousness may vary with adenoviral serotype o based on retrospective chart review an in vitro infectivity titers of 90 clinical ocular adenoviral isolates o positive cultures in second week of disease reported for  adenovirus serotype 8 in 9 of 33 (27%) patients  other adenoviral serotypes in 2 of 54 (4%) patients o Reference - Cornea 1995 Jul;14(4):388

Medications: 

1 drop may be sufficient dose for most prescription eye drops o volume of single drop typically 35-50 mcL o eye can only hold 30 mcL of fluid o waiting 5 minutes between drops recommended when 2 different drops used o Reference - Med Lett Drugs Ther 2006 Jun 19;48(1237):49 TOC

Antibiotics: Some antibiotic ophthalmic preparations for conjunctivitis:   

antibiotic selection based on in vitro coverage 10% sodium sulfacetamide topical drops or ointment 4 times daily for 1 week; sulfacetamide can be sensitizing, rarely causes Stevens-Johnson syndrome polymyxin B plus trimethoprim (Polytrim) every 3-4 hours for 7-10 days o trimethoprim has broad spectrum of activity, including methicillin-resistant S. aureus (MRSA) o polymyxin B only covers gram-negative organisms, so relatively ineffective alone; usually prepared with other medications as in AK-Poly-Bac, Cortisporin, Maxitrol, Polytrim fluoroquinolones o broad spectrum of activity, but MRSA may be resistant o besifloxacin ophthalmic suspension 0.6% (Besivance) FDA approved for treatment of bacterial conjunctivitis in patients ≥ 1 year old (FDA Press Release 2009 May 28) o ciprofloxacin (Ciloxan)  ointment into conjunctival sac of affected eye(s) 3 times daily for 2 days, then twice daily for next 5 days


     

0.3% solution 1-2 drops into conjunctival sac of affected eye(s) every 2 hours while awake for 2 days, then 1-2 drops every 4 hours while awake for next 5 days o gatifloxacin (Zymar) 0.3% 4-8 times daily for 5 days o levofloxacin (Quixin) 0.5% drops every 2 hours for 2 days then every 4 hours for 3 days (5 days total) o moxifloxacin (Vigamox) 0.5% 1 drop 2-3 times daily for 3-7 days o ofloxacin (Ocuflox) 0.3% drops every 2 hours for 2 days then every 4 hours for 3 days (5 days total) o comparative efficacy  moxifloxacin (Vigamox) and gatifloxacin (Zymar) may be more effective in vitro against S. aureus and some anaerobes resistant to ciprofloxacin (Ciloxan) and ofloxacin (Ocuflox)  fluoroquinolone eye drops considered second-line agents if resistance to sulfacetamide, Neosporin, erythromycin, gentamicin or tobramycin (Prescriber's Letter 2003 May;10(5):27) gentamicin or tobramycin - most streptococci are resistant in vitro bacitracin - not active against gram-negative organisms (small percentage of bacterial conjunctivitis) erythromycin - not active against gram-negative organisms (small percentage of bacterial conjunctivitis) neomycin - may cause local reactions in 5%-10% patients Reference - Med Lett Drugs Ther 2004 Mar 29;46(1179):25 TOC azithromycin 1% ophthalmic solution (AzaSite) FDA approved for bacterial conjunctivitis o dose 1 drop twice daily for 2 days then 1 drop once daily for 5 days o most common adverse effect is eye irritation o considered safe for use during pregnancy o Reference - Med Lett Drugs Ther 2008 Feb 11;50(1279):11 TOC azithromycin 1.5% (Azyter) eye drops 1 drop twice daily for 3 days approved in Europe

Antibiotic efficacy for bacterial conjunctivitis: 

topical antibiotics improve rate of early clinical remission in patients with acute bacterial conjunctivitis (level 1 [likely reliable] evidence) o based on Cochrane review o systematic review of 11 randomized trials comparing antibiotics vs. placebo in 3,673 patients with acute bacterial conjunctivitis o all antibiotics evaluated were topical (azithromycin in DuraSite, polymyxin/bacitracin, ciprofloxacin, norfloxacin, fusidic acid, chloramphenicol, moxifloxacin, and besifloxacin) o antibiotics associated with increased  early clinical remission (days 2-5) in analysis of 6 trials with 2,116 patients  risk ratio (RR) 1.36 (95% CI 1.15-1.61)


o o o

NNT 6-23 with early clinical remission in 29% in placebo group  late clinical remission (days 6-10) in analysis of 8 trials with 2,353 patients  RR 1.21 (95% CI 1.1-1.33)  NNT 8-25 with late clinical remission in 41% in placebo group authors note that many cases resolve spontaneously with 41% clinical remission with placebo by 6-10 days no serious adverse outcomes reported Reference - Cochrane Database Syst Rev 2012 Sep 12;(9):CD001211 , earlier version published in Br J Gen Pract 2005 Dec;55(521):962, commentary on earlier version can be found in Evid Based Med 2006 Dec;11(6):180

antibiotics (immediate or delayed) associated with reduced duration of symptoms, delayed antibiotics associated with reduced return visit rate (level 2 [mid-level] evidence) o based on randomized trial without blinding o 307 patients ≥ 1 year old (55% ≥ 12 years old) with acute infective conjunctivitis underwent 3 separate randomizations  immediate antibiotics (chloramphenicol eye drops every 2 hours for 2 days and then 4 times daily) vs. delayed antibiotics (prescription to be obtained from office after 3 days) vs. no antibiotics  patient information leaflet vs. no leaflet  eye swab for microbiology vs. no eye swab o 249 (81%) patients completed diaries for outcomes o antibiotics associated with reduced symptom duration but not symptom severity 

Outcomes:

99%

Delayed Antibiotics 53%

No Antibiotics 30%

3.3 days

3.9 days

4.8 days

1.9

2

2.1

Antibiotics Use of antibiotics Duration of moderate symptoms Mean symptom score days 1-3 o o

57 patients (19%) had return visit for conjunctivitis within 1 year, including 29 (9%) within 2 weeks compared to no antibiotics (absolute numbers not reported)  return visit rate within 2 weeks reduced with delayed antibiotics (odds ratio 0.3, 95% CI 0.1-1)


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return visit rate within 2 weeks not significantly reduced with immediate antibiotics (odds ratio 0.7, 95% CI 0.3-1.6) no significant differences in any outcomes based on receipt of patient information leaflet or eye swab Reference - BMJ 2006 Aug 12;333(7563):321 , correction can be found in BMJ 2006 Sep 2;333(7566):468, editorial can be found in BMJ 2006 Aug 12;333(7563):311, commentary can be found in BMJ 2006 Aug 26;333(7565):446, J Fam Pract 2006 Dec;55(12):1031, Evid Based Med 2007 Jun;12(3):93

polymyxin B-trimethoprim may be as effective as moxifloxacin for cure of acute conjunctivitis in children (level 2 [mid-level] evidence) o based on randomized noninferiority trial without intention-to-treat analysis o 124 patients aged 1-18 years with acute conjunctivitis randomized to ophthalmic solution polymyxin B-trimethoprim 4 times daily vs. moxifloxacin 3 times daily for 7 days o 65% had recognized ocular pathogens (as assessed by conjunctiva cultures) o clinical cure defined as complete resolution of all signs and symptoms of conjunctivitis o noninferiority criterion defined as lower limit of 90% CI ≤ 20% for difference between groups in clinical cure rate o 8% at 4-6 days and 28% at 7-10 days did not complete follow-up and were excluded from analyses o comparing polymyxin B-trimethoprim vs. moxifloxacin  clinical cure based on parent report at days 4-6 in 72% vs. 77% (noninferiority established)  clinical cure based on evaluation at days 7-10 in 96% vs. 95% (noninferiority established) o no significant difference in bacteriological cure at days 4-6 or 7-10 o Reference - J Pediatr 2013 Apr;162(4):857

fluoroquinolone eye drops appear effective o besifloxacin ophthalmic suspension 0.6% appears effective in patients with bacterial conjunctivitis (level 2 [mid-level] evidence)  based on 2 randomized trials with allocation concealment not stated  957 patients ≥ 1 year old with bacterial conjunctivitis randomized to besifloxacin ophthalmic suspension 0.6% vs. placebo 3 times daily for 5 days  comparing besifloxacin vs. placebo in 399 patients with culture-confirmed conjunctivitis  clinical resolution at day 8 or 9 in 84.4% vs. 69.1% (p = 0.0011, NNT 7)  microbial eradication at day 8 or 9 in 88.4% vs. 71.7% (p < 0.0001, NNT 6)  adverse events in 9.2% vs. 13.9% (p = 0.0047, NNT 22)  Reference - Curr Med Res Opin 2009 May;25(5):1159


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o

o

269 patients (mean 34.2 years) with acute bacterial conjunctivitis randomized to topical besifloxacin ophthalmic suspension vs. placebo 3 times daily for 5 days  culture-confirmed intent-to-treat population consisted of 118 patients  comparing besifloxacin vs. placebo  clinical infection resolution in 73.3% vs. 43.1% (p < 0.001, NNT 4)  bacterial eradication 88.3% vs. 60.3% (p < 0.001, NNT 4)  adverse events in 50.4% vs. 53% (not significant)  most common adverse events were mild-moderate eye pain, blurred vision, and eye irritation  Reference - Clin Ther 2009 Mar;31(3):514 besifloxacin 0.6% ophthalmic suspension may be as effective as moxifloxacin 0.5% ophthalmic suspension 3 times daily for 5 days in acute bacterial conjunctivitis (level 2 [mid-level] evidence)  based on randomized trial with incomplete blinding  1,161 patients > 1 year old with conjunctivitis randomized to besifloxacin 0.6% vs. moxifloxacin 0.5% ophthalmic suspension 3 times daily for 5 days  study medications differed in appearance so assessors were not permitted to watch any dosing that occurred in office  533 patients had bacterial conjunctivitis confirmed by culture and included in efficacy analysis  1,161 patients included in safety analysis  comparing besifloxacin vs. moxifloxacin  clinical resolution of symptoms at 5 days in 58.3% vs. 59.4% (not significant)  clinical resolution of symptoms at 8 days in 84.5% vs. 84% (not significant)  total ocular adverse events in 12% and 14% (not significant)  eye irritation in 0.3% vs. 1.4% (p = 0.0201, NNT 91)  Reference - Ophthalmology 2009 Sep;116(9):1615 gatifloxacin 0.3% 4-8 times daily for 5 days appears effective (level 2 [mid-level] evidence)  based on unpublished placebo-controlled trial with 100 culturepositive patients  77% vs. 58% efficacy (NNT 6)  Reference - Med Lett Drugs Ther 2004 Mar 29;46(1179):25 TOC levofloxacin and ofloxacin eye drops may have similar clinical cure rates (level 2 [mid-level] evidence)  based on randomized trial with high dropout rate  423 patients with clinical diagnosis of bacterial conjunctivitis randomized to levofloxacin 0.5% vs. ofloxacin 0.3% eye drops every 2 hours for 2 days then every 4 hours for 3 days (5 days total)  208 patients (49%) evaluated for efficacy


 

> 80% of subjects had resolution of signs and symptoms at endpoint no significant differences in signs and symptoms at endpoint including conjunctival discharge, conjunctival injection, swelling, redness, stinging, except for photophobia  resolution of photophobia in 94% of patients receiving levofloxacin vs. 73% patients receiving ofloxacin (p = 0.006, NNT 5)  microbial eradication rates higher with levofloxacin (90% vs. 81%, (p = 0.038, NNT 11)  Reference - Ophthalmology 2003 Mar;110(3):457 azithromycin eye drops appear effective o azithromycin 1% ophthalmic solution appears effective for children and adults with bacterial conjunctivitis (level 2 [mid-level] evidence)  based on randomized trial without intention-to-treat analysis  683 patients aged 1-96 years with conjunctivitis randomized to azithromycin 1% in DuraSite vs. vehicle alone for 5 days (twice daily for 2 days then once daily for 3 days)  279 patients with bacterial growth on culture who took at least 1 dose of medication were evaluated  clinical resolution at 6-7 days in 63% azithromycin group vs. 50% control group (p = 0.03, NNT 8)  Reference - Am J Ophthalmol 2008 Jun;145(6):959 o topical azithromycin 1.5% twice daily for 3 days appears as effective as 7-day course of tobramycin (level 2 [mid-level] evidence)  based on randomized trial with allocation concealment and follow-up rates not stated  1,043 adults, children or infants with purulent bacterial conjunctivitis were randomized to azithromycin 1.5% (Azyter) eye drops 1 drop twice daily for 3 days vs. tobramycin 0.3% (Tobrex) eye drops 1 drop every 2 hours up to 8 times/day for 2 days and then 4 times daily for 5 days  outcome assessor blinded  521 patients had positive bacterial cultures at baseline, of whom 471 without protocol deviations were included in per-protocol analysis  comparing azithromycin vs. tobramycin for clinical cure at 9 days  87.8% vs. 89.4% in per-protocol analysis (95% CI for difference -7.5% to +4.4%)  85.6% vs. 86.1% in modified intention-to-treat analysis of 521 patients (95% CI for difference -6.6% to +5.8%)  85.3% vs. 84.8% in intention-to-treat analysis (95% CI for difference -3.8% to +4.9%)  Reference - Br J Ophthalmol 2007 Apr;91(4):465  topical azithromycin 1.5% twice daily for 3 days appears as effective as 7-day course of tobramycin in children and adolescents (level 2 [mid-level] evidence)  based on subgroup analysis of randomized trial including 150 children and adolescents with purulent bacterial conjunctivitis


  

39% had positive cultures (included in efficacy analysis) similar clinical and microbiologic cure rate (> 80% on day 9) Reference - Pediatr Infect Dis J 2010 Mar;29(3):222 povidone-iodine 1.25% ophthalmic solution may be as effective as neomycinpolymyxin B-gramicidin for infectious conjunctivitis in children (level 2 [midlevel] evidence) o based on non-randomized trial o 459 children (aged 7 months to 21 years) with acute conjunctivitis in ophthalmology clinic in Philippines given by alternative assignment povidone-iodine 1.25% vs. neomycin-polymyxin B-gramicidin ophthalmic solution 1 drop 4 times daily in affected eye o no significant differences in days to cure or cure rates at 1 or 2 weeks o povidone-iodine 1.25% was marginally more effective for chlamydial infections o Reference - Am J Ophthalmol 2002 Nov;134(5):681 ofloxacin may be more effective than aminoglycosides for ophthalmic use (level 3 [lacking direct] evidence) o based on 2 in vitro studies o fluoroquinolones may have greater antimicrobial activity than other antibiotics of ocular bacteria (level 3 [lacking direct] evidence)  based on in vitro testing of 419 ocular bacterial isolates of 55 species  agents tested were ofloxacin, norfloxacin, gentamicin, tobramycin, chloramphenicol, and polymyxin B  ofloxacin had greatest in vitro efficacy  Reference - Am J Ophthalmol 1989 Oct 15;108(4):380 o ofloxacin may provide effective concentrations in tears longer than gentamicin or tobramycin (level 3 [lacking direct] evidence)  based on study in rabbits  single topical doses given to rabbits for ofloxacin 0.3%, gentamicin 0.3% and tobramycin 0.3%  tear samples tested for 6 hours  mean antibiotic concentration > MIC90 lasted for  > 4 hours for ofloxacin  20 minutes for gram-positive organisms and 120 minutes for gram-negative organisms with gentamicin  10 minutes for tobramycin  Reference - Antimicrob Agents Chemother 1990 Aug;34(8):1602 PDF

Antibiotic resistance: 

fluoroquinolones reported to be active against most ocular bacterial isolates, but methicillin-resistant S. aureus (MRSA) only susceptible to trimethoprim (level 3 [lacking direct] evidence) o based on national study in United States


o

278 prospectively collected ocular isolates and 1,116 archived ocular isolates of Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae were evaluated o methicillin-sensitive S. aureus - about 80% susceptible to fluoroquinolones o methicillin-resistant S. aureus (MRSA) - only 15% susceptible to fluoroquinolones; only antibiotic tested with high activity was trimethoprim o S. pneumoniae - 100% susceptible to gatifloxacin, levofloxacin, and moxifloxacin; 90% susceptible to ciprofloxacin o H. influenzae - 100% susceptible to all tested agents but trimethoprim o Reference - Ocular Tracking Resistance in United States Today (TRUST) annual study (Am J Ophthalmol 2008 Jun;145(6):951) increasing resistance to ciprofloxacin and erythromycin reported in bacterial conjunctivitis (level 3 [lacking direct] evidence) o based on retrospective study of 2,408 eyes with conjunctivitis in South Florida o Reference - Ophthalmology 2008 Jan;115(1):51

Antibiotic adverse effects: 

allergic reactions to some topical antibiotics reported in 7-19% patients (level 3 [lacking direct] evidence) o based on series of 27 patients with prolonged or chronic conjunctivitis o 18.5% had allergic reactions to topical neomycin o 7.4% had allergic reactions to topical bacitracin o Reference - Acta Ophthalmol (Copenh) 1985 Aug;63(4):424 topical ocular antibiotics significantly associated with drug reactions in epidemiologic study include bacitracin, chloramphenicol, gentamicin, gramicidin, neomycin, polymyxin, and sulfacetamide (Trans Am Ophthalmol Soc 1983;81:854 PDF)

Antibiotics which are not supported as effective: 

chloramphenicol no more effective than placebo in acute conjunctivitis in children (level 1 [likely reliable] evidence) o based on randomized trial o 326 children aged 6 months to 12 years with clinical diagnosis of conjunctivitis randomized to chloramphenicol vs. placebo eye drops o comparing chloramphenicol vs. placebo  clinical cure at 7 days in 86% vs. 83% (risk difference 3.8%, 95% CI -4.1% to 11.8%)  further conjunctivitis episodes within 6 weeks in 4% vs. 3% (risk difference 1.2%, 95% CI -2.9% to 5.3%)  microbiological cure rate at 7 days 40% vs. 23% (NNT 6)  clinical cure rate 85% vs. 80% in subgroup of 236 patients with bacterial pathogen (risk difference 4.6%, 95% CI -5.1% to 14.2%) o Reference - Lancet 2005 Jul 2;366(9479):37, editorial can be found in Lancet 2005 Jul 2-8;366(9479):6, commentary can be found in Lancet 2005


Oct 22;366(9495):1431, Evidence-Based Medicine 2006 Jan-Feb;11(1):18, Am Fam Physician 2006 Mar 15;73(6):1094 o systemic absorption of chloramphenicol with prolonged use has caused aplastic anemia (Med Lett Drugs Ther 2004 Mar 29;46(1179):25 TOC) fusidic acid gel not clearly effective in adults with acute infectious conjunctivitis (level 2 [mid-level] evidence) o based on randomized trial with inadequate power to rule out small clinical differences o 181 adults presenting to 25 Dutch primary care centers with red eye and either muco-purulent discharge or glued eyelid randomized to fusidic acid gel 1% 1 drop four times daily for 7 days vs. placebo o 163 patients (90%) analyzed o recovery rate 62% with fusidic acid vs. 59% with placebo (not significant) o no significant difference in median duration of symptoms o only 32% had positive bacterial culture at baseline o comparing fusidic acid vs. placebo in culture positive patients  bacterial eradication in 76% vs. 41% (95% CI = 9.3-60.4)  clinical recovery in culture positive patients odds ratio (adjusted for age) for 2.58 (95% CI 0.79-8.42) in favor of fusidic acid o Reference - Br J Gen Pract 2005 Dec;55(521):924

Treatment of gonococcal and chlamydial conjunctivitis: 

Centers for Disease Control and Prevention (CDC) recommendations for gonococcal and chlamydial conjunctivitis o systemic antibiotics recommended; topical therapy alone is not sufficient and it is unnecessary if systemic therapy given o gonococcal conjunctivitis  for adults  give ceftriaxone 1 g intramuscularly once  consider lavage with saline solution of the infected eye once  treat concurrently for presumptive chlamydial conjunctivitis  for infants  give ceftriaxone 25-50 mg/kg (maximum 125 mg) IV or intramuscularly as single dose  test infant and mother for chlamydia also  consider concurrent chlamydia infection if patient does not respond after treatment o chlamydial conjunctivitis  for children who weigh < 45 kg including neonates, erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days  for children aged < 8 years old who weigh ≥ 45 kg, azithromycin 1 g orally in a single dose  for children aged ≥ 8 years old and adults, azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days


o

Reference - MMWR Recomm Rep 2010 Dec 17;59(RR-12):1 , correction can be found in MMWR 2011 Jan 14;60(01):18 oral erythromycin in first 2 weeks of life associated with 8 times increased risk for infantile hypertrophic pyloric stenosis (level 2 [mid-level] evidence) o based on retrospective cohort study o 314,029 infants followed for first 90 days of life, 7,138 (2.3%) were prescribed oral erythromycin, 804 (0.26%) developed pyloric stenosis o exposure to oral erythromycin on days 3-13 of life associated with nearly 7.88 times increased risk (95% CI 1.97-31.57) o no increase in risk for erythromycin given after age 14 days o no increase in risk with other antibiotics o Reference - Arch Pediatr Adolesc Med 2002 Jul;156(7):647 oral azithromycin and doxycycline appear to have similar efficacy for chlamydial conjunctivitis (level 2 [mid-level] evidence) o based on randomized trial with high dropout rate and without blinding o 78 adults with inclusion conjunctivitis due to Chlamydia trachomatis randomized to doxycycline 100 mg orally twice daily for 10 days vs. azithromycin 1 g orally once o only 51 (65%) completed the study o no significant differences in rates of clinical cure (69% vs. 60%) or microbiologic cure (96% vs. 92%) o study too small to rule out clinical differences o Reference - Am J Ophthalmol 2003 Apr 1;135(4):447

Anti-inflammatory drugs: 

ketorolac eye drops do not appear effective for viral conjunctivitis (level 2 [mid-level] evidence) o based on randomized trial with allocation concealment not stated o 117 patients with viral conjunctivitis randomized to ketorolac 0.5% (Acular) vs. artificial tears (Moisture Drops) 1 drop 4 times daily for 7 days o 105 returned for follow-up at 3-4 days o no significant differences in outcomes except artificial tear groups reported more improvement in redness o 59% ketorolac vs. 19% control group reported stinging (p < 0.001, NNH 2) o Reference - Ophthalmology 2000 Aug;107(8):1512

topical dexamethasone may not reduce symptoms of viral conjunctivitis compared to placebo (level 2 [mid-level] evidence) o based on randomized trial with high dropout rate and inadequate statistical power o 111 patients with acute follicular conjunctivitis presumed viral in origin randomized to dexamethasone 0.1% drops vs. hypromellose 0.3% drops 4 times/day for 1 week o 21% dropped out and excluded from analyses o no significant differences between groups in patient level of discomfort or conjunctival hyperemia


o o

o

no serious complications comparing  mild or no symptoms at 5-7 days in 95% vs. 87% (no p value reported)  patient's favorable impression of treatment in 87% vs. in 70% (p = 0.0248) Reference - Br J Ophthalmol 2011 Sep;95(9):1299

Follow-up:   

viral conjunctivitis - refer if symptoms not resolved after 7-10 days or if corneal involvement(3) bacterial conjunctivitis - refer if symptoms not improved within 1 week of treatment(3, 4) hyperacute gonococcal conjunctivitis - follow up daily, refer if there is no improvement(4)

Prognosis 

acute bacterial conjunctivitis is usually self-limited o based on Cochrane review o systematic review and meta-analysis of 5 randomized trials of antibiotics for acute bacterial conjunctivitis in 1,034 patients o most cases resolved spontaneously, with 65% clinical remission by days 2-5 with placebo o no serious outcomes reported, indicating that sight-threatening complications are infrequent o Reference - systematic review last updated 2006 Jan 23 (Cochrane Library 2006 Issue 2:CD001211), also published in Br J Gen Pract 2005 Dec;55(521):962, commentary can be found in Evid Based Med 2006 Dec;11(6):180 viral conjunctivitis is self-limited but may be associated with persistent morbidity o median duration of adenoviral keratoconjunctivitis 5 weeks  based on retrospective cohort of 54 consecutive patients with adenoviral keratoconjunctivitis  symptoms > 45 days in 25.9%  Reference - Cornea 2006 Feb;25(2):199 o up to 50% patients with epidemic keratoconjunctivitis develop subepithelial infiltrates or chronic dry eyes; subepithelial infiltrates may cause months or years of poor vision, discomfort and light sensitivity (Gerontology 2007;53(5):250, Br Med J 1973 Apr 21;2(5859):165 PDF, Ann Ophthalmol 1991 Feb;23(2):63, Cornea 2006 Feb;25(2):199) dry eye reported for almost 1 month following recovery from acute conjunctivitis in series of 56 patients (73 eyes) (Cornea 2007 Aug;26(7):778)

Prevention and Screening


Prevention:  

prophylactic topical antimicrobials (such as erythromycin or silver nitrate eye drops) recommended for all newborns to prevent ophthalmia neonatorum healthcare personnel with epidemic keratoconjunctivitis or purulent conjunctivitis should not participate in patient care for duration of symptoms (Centers for Disease Control and Prevention guidelines for infection control in hospital personnel in Infect Control Hosp Epidemiol 1998 Jun;19(6):407 PDF) exclusion from school for conjunctivitis is controversial o no current consensus exists among state health officials o exclusion from school recommended in children with conjunctivitis until they are asymptomatic in one review (J Pediatr Ophthalmol Strabismus 2007 Mar-Apr;44(2):101) o no recommended exclusion period from school in another review (UK expert Grade C, Level III)  exclusion not required as generally mild illness in children  Reference - Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184

Guidelines and Resources Guidelines: United States guidelines: 

American Academy of Ophthalmology (AAO) guideline on conjunctivitis can be found at or at National Guideline Clearinghouse 2012 Jul 16:36093

Work Loss Data Institute (WLDI) guideline on disorders of eye can be found at National Guideline Clearinghouse 2011 Jul 11:25694

United Kingdom guidelines: 

expert guideline on exclusion policies for control of communicable disease in schools and preschools can be found in Pediatr Infect Dis J 2001 Apr;20(4):380, correction can be found in Pediatr Infect Dis J 2001 Jul;20(7):653, commentary can be found in Pediatr Infect Dis J 2001 Dec;20(12):1184

Asian guidelines: 

Japanese Society of Chemotherapy Committee/Japanese Association for Anaerobic Infection Research guidelines on anaerobic infections (individual fields): opthalmologic infections can be found in J Infect Chemother 2011 Jul;17 Suppl 1:108

Review articles:


  

          

review of management of acute infectious conjunctivitis can be found in N Z Med J 2009 Jul 3;122(1298):69 review of management strategies for acute infectious conjunctivitis can be found in Expert Opin Pharmacother 2007 Aug;8(12):1903 review of conjunctivitis can be found in Am Fam Physician 1998 Feb 15;57(4):735 , commentary that tetracycline is safe in breastfeeding women can be found in Am Fam Physician 1998 Oct 15;58(6):1306 case presentation of viral conjunctivitis can be found in J Fam Pract 2004 Mar;53(3):189 brief "What you should do" review of red eye can be found in BMJ 2005 Aug 20;331(7514):438 review of the red eye can be found in N Engl J Med 2000 Aug 3;343(5):345, commentary can be found in N Engl J Med 2000 Nov 23;343(21):1577 review of common eye problems in primary care can be found in Postgrad Med 2000 Oct;108(5):83 review of common eye problems in children can be found in Am Fam Physician 2001 Aug 15;64(4):623 review of work-related eye injuries and illnesses can be found in Am Fam Physician 2007 Apr 1;75(7):1017 review of Neisseria gonorrhoeae infections can be found in Am Fam Physician 2006 May 15;73(10):1779 review of chlamydia and gonorrhea can be found in Ann Intern Med 2013 Feb 5;158(3):ITC2 review of drugs for some common eye disorders can be found in Treat Guidel Med Lett 2010 Jan;8(89):1 review of correct use of eye drops can be found in Australian Prescriber 2008 Feb;31:16 case presentation of pingueculitis can be found in Am Fam Physician 2007 Sep 15;76(6):857

MEDLINE search: 

to search MEDLINE for (Infectious conjunctivitis) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis

Patient InformationICD-9/ICD-10 CodesReferences General references used: 

 

1. Høvding G. Acute bacterial conjunctivitis. Acta Ophthalmol. 2008 Feb;86(1):517, editorial can be found in Acta Ophthalmol 2008 Feb;86(1):2, commentary can be found in Acta Ophthalmol 2008 Sep;86(6):692 2. Mah F. Bacterial conjunctivitis in pediatrics and primary care. Pediatr Clin North Am. 2006 May;53 Suppl 1:7-10; quiz 11, 13-5. 3. Cronau H, Kankanala R, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician 2010 Jan 15;81(2):137


 

4. Hutnik C, Thomas M, Visscher K. Evidence-based treatment of acute infective conjunctivitis. Can Fam Physician 2009 Nov;55(11):1071 5. O'Brien TP, Jeng BH, McDonald M, Raizman MB. Acute conjunctivitis: truth and misconceptions. Curr Med Res Opin. 2009 Aug;25(8):1953-61.

Recommendation grading systems used: 

grades of recommendation from guideline commissioned by United Kingdom (UK) Government Department for Education and Employment and Department of Health o grades of recommendation  Grade A - derived from Level I evidence of period of infectiousness and/or effectiveness of exclusion  Grade B - derived from Level II evidence of period of infectiousness and/or effectiveness of exclusion, or Level I-II evidence of duration of shedding and/or serial interval  Grade C - derived from Level III or IV evidence of period of infectiousness, effectiveness of exclusion, duration of shedding, and/or serial interval o levels of evidence  Level I - systematic review, meta-analysis, or well-designed epidemiologic or experimental study with ≥ 50 subjects  Level II - well-designed epidemiologic or experimental study with 550 subjects  Level III - case reports with < 5 subjects, or poorly substantiated larger study  Level IV - opinion or clinical experience of experts (not supported by published data) o Reference - Pediatr Infect Dis J 2001 Apr;20(4):380

DynaMed editorial process:  

  

DynaMed topics are created and maintained by the DynaMed Editorial Team. Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-Step evidence-based method for systematic literature surveillance. DynaMed topics are updated daily as newly discovered best available evidence is identified. The participating members of the DynaMed Editorial Team have declared that they have no financial or other competing interests related to this topic. The participating reviewers have declared that they have no financial or other competing interests related to this topic, unless otherwise indicated. McMaster University is a partner that provides support in identifying PracticeChanging DynaMed Updates. Over 1,000 practicing physicians from 61 disciplines in 77 countries rate these articles to help you find the most useful new evidence affecting your practice. F1000 is a partner that provides support in identifying Practice-Changing DynaMed Updates. Over 2,000 practicing clinicians from 20 disciplines in 60 countries rate these articles to help you find the most useful new evidence affecting your practice.


Special acknowledgements: ď&#x201A;ˇ

Robert Sambursky, MD (Ophthalmologist, Manatee Sarasota Eye Clinic; Florida, United States) provides peer review.

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For attribution in other publications see How to Cite Information from DynaMed.

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